Provider First Line Business Practice Location Address:
3910 N POWELTON 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:
19104-2640
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-662-8747
Provider Business Practice Location Address Fax Number:
215-243-3258
Provider Enumeration Date:
04/09/2013