Provider First Line Business Practice Location Address:
406 N 65TH 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:
19151-4003
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-791-8430
Provider Business Practice Location Address Fax Number:
888-493-3438
Provider Enumeration Date:
07/23/2026