Provider First Line Business Practice Location Address:
5201 OLD YORK RD
Provider Second Line Business Practice Location Address:
SUITE 103
Provider Business Practice Location Address City Name:
PHILADELPHIA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19141-2985
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
267-331-8153
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/22/2007