Provider First Line Business Practice Location Address:
1416 S 55TH 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:
19143-4907
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
267-992-1376
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/31/2025