Provider First Line Business Practice Location Address:
439 WEST CHEW AVE 1ST F
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:
19120
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
267-297-7052
Provider Business Practice Location Address Fax Number:
267-297-7954
Provider Enumeration Date:
02/26/2014