Provider First Line Business Practice Location Address:
602 N 16TH ST
Provider Second Line Business Practice Location Address:
APT T
Provider Business Practice Location Address City Name:
PHILADELPHIA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19130-3423
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
573-639-0202
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/19/2015