Provider First Line Business Practice Location Address:
27 S. 55TH STREET
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:
19139-3247
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
267-499-4299
Provider Business Practice Location Address Fax Number:
267-713-7372
Provider Enumeration Date:
02/06/2019