Provider First Line Business Practice Location Address:
1127 S 48TH 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:
19143-3546
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
267-210-9748
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/30/2021