Provider First Line Business Practice Location Address:
1423 E. LUZERNE ST.
Provider Second Line Business Practice Location Address:
1ST FLOOR
Provider Business Practice Location Address City Name:
PHILADELPHIA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19124-5361
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
267-686-4177
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/10/2016