Provider First Line Business Practice Location Address:
4742 PENN 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:
19124-5823
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-744-8338
Provider Business Practice Location Address Fax Number:
215-744-8338
Provider Enumeration Date:
02/28/2017