Provider First Line Business Practice Location Address:
130 S 18TH ST
Provider Second Line Business Practice Location Address:
UNIT #1401
Provider Business Practice Location Address City Name:
PHILADELPHIA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19103-4923
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
302-547-8394
Provider Business Practice Location Address Fax Number:
610-527-8434
Provider Enumeration Date:
06/29/2012