Provider First Line Business Practice Location Address:
5115 W DAKOTA ST
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:
19131-2414
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-380-4282
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/06/2015