Provider First Line Business Practice Location Address:
1021 S 21ST 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:
19146-2634
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-790-9942
Provider Business Practice Location Address Fax Number:
215-790-9947
Provider Enumeration Date:
01/15/2009