Provider First Line Business Practice Location Address:
2022 S 67TH 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:
19142-1625
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-729-4016
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/30/2009