Provider First Line Business Practice Location Address:
1241 N TANEY 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:
19121-4660
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-236-6634
Provider Business Practice Location Address Fax Number:
215-236-6692
Provider Enumeration Date:
09/12/2006