Provider First Line Business Practice Location Address:
5520 WHITAKER AVE UNIT C
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:
19124-1705
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-288-8701
Provider Business Practice Location Address Fax Number:
215-288-8702
Provider Enumeration Date:
09/21/2010