Provider First Line Business Practice Location Address:
1144 N 4TH 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:
19123-1503
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
267-349-5316
Provider Business Practice Location Address Fax Number:
888-678-2884
Provider Enumeration Date:
05/04/2015