Provider First Line Business Practice Location Address:
21 S 11TH 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:
19107-4223
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-578-1507
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/31/2020