Provider First Line Business Practice Location Address:
1532 E PASSYUNK AVE APT 1
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:
19147-6380
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-279-3932
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/17/2026