Provider First Line Business Practice Location Address:
3800 JASPER ST
Provider Second Line Business Practice Location Address:
UNIT 3
Provider Business Practice Location Address City Name:
PHILADELPHIA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19124-5631
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-764-8803
Provider Business Practice Location Address Fax Number:
215-827-5608
Provider Enumeration Date:
06/26/2008