Provider First Line Business Practice Location Address:
2151 S 19TH ST
Provider Second Line Business Practice Location Address:
2ND FLOOR
Provider Business Practice Location Address City Name:
PHILADELPHIA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19145-3709
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-681-0337
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/16/2012