Provider First Line Business Practice Location Address:
1200 INTREPID 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:
19112-1229
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
714-924-0607
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/07/2022