Provider First Line Business Practice Location Address:
50 S 61ST 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:
19139-3009
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-245-2131
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/02/2019