Provider First Line Business Practice Location Address:
4654 N 5TH 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:
19140-1420
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
267-237-1188
Provider Business Practice Location Address Fax Number:
267-900-2131
Provider Enumeration Date:
03/08/2016