Provider First Line Business Practice Location Address:
2925 N 12TH 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:
19133-1326
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
267-323-0047
Provider Business Practice Location Address Fax Number:
215-225-1211
Provider Enumeration Date:
09/16/2024