Provider First Line Business Practice Location Address:
664 W JOHNSON 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:
19144-3706
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-694-8529
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/07/2017