Provider First Line Business Practice Location Address:
2603 CECIL B MOORE 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:
19121-2826
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-769-7045
Provider Business Practice Location Address Fax Number:
215-769-7046
Provider Enumeration Date:
06/04/2012