Provider First Line Business Practice Location Address:
1412 FAIRMOUNT 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:
19130
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-599-4851
Provider Business Practice Location Address Fax Number:
215-232-4093
Provider Enumeration Date:
05/18/2007