Provider First Line Business Practice Location Address:
1204 E HUNTING PARK 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:
19124-4904
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-289-3711
Provider Business Practice Location Address Fax Number:
215-831-8126
Provider Enumeration Date:
09/14/2006