Provider First Line Business Practice Location Address:
3823 J ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PHILA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19124-5405
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-288-0157
Provider Business Practice Location Address Fax Number:
215-288-4764
Provider Enumeration Date:
05/15/2006