Provider First Line Business Practice Location Address:
407 FAIRMOUNT AVE
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:
19123-2807
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-796-2481
Provider Business Practice Location Address Fax Number:
215-627-6766
Provider Enumeration Date:
12/27/2007