Provider First Line Business Practice Location Address:
3300 GRANT AVE
Provider Second Line Business Practice Location Address:
UNIT 19C
Provider Business Practice Location Address City Name:
PHILADELPHIA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19114-2614
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-754-8743
Provider Business Practice Location Address Fax Number:
215-754-4450
Provider Enumeration Date:
10/17/2014