Provider First Line Business Practice Location Address:
4530 TEESDALE 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:
19136-4012
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-868-6928
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/07/2025