Provider First Line Business Practice Location Address:
4613 BALTIMORE AVE
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:
19143
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-386-0334
Provider Business Practice Location Address Fax Number:
215-386-9323
Provider Enumeration Date:
05/19/2008