Provider First Line Business Practice Location Address:
395 E UPSAL 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:
19119-2031
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
347-314-2955
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/09/2019