Provider First Line Business Practice Location Address:
5304 N 5TH 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:
19120-3204
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-455-2411
Provider Business Practice Location Address Fax Number:
215-457-0469
Provider Enumeration Date:
07/22/2006