Provider First Line Business Practice Location Address:
1724 S 22ND ST UNIT A
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:
19145-1953
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
267-613-7889
Provider Business Practice Location Address Fax Number:
401-340-1770
Provider Enumeration Date:
06/05/2026