Provider First Line Business Practice Location Address:
6012 RIDGE 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:
19128-1643
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
217-487-1990
Provider Business Practice Location Address Fax Number:
215-487-1992
Provider Enumeration Date:
05/31/2007