Provider First Line Business Practice Location Address:
821 E UPSAL 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:
19119-1542
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-764-9679
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/07/2016