Provider First Line Business Practice Location Address:
8220 CASTOR AVENUE
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:
19152
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-728-4648
Provider Business Practice Location Address Fax Number:
267-350-4887
Provider Enumeration Date:
10/21/2006