Provider First Line Business Practice Location Address:
100 E LEHIGH AVE BLDG SUITE105
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PHILADELPHIA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19125-1012
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-707-8496
Provider Business Practice Location Address Fax Number:
215-707-4086
Provider Enumeration Date:
05/22/2024