Provider First Line Business Practice Location Address:
1638 SOUTH ST UNIT 9
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:
19146-1542
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-545-0320
Provider Business Practice Location Address Fax Number:
215-545-0260
Provider Enumeration Date:
12/29/2012