Provider First Line Business Practice Location Address:
1411 HARRISON 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:
19124-5932
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-289-8832
Provider Business Practice Location Address Fax Number:
215-289-3497
Provider Enumeration Date:
11/12/2007