Provider First Line Business Practice Location Address:
5530 CHESTER 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:
19143-5328
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-729-8225
Provider Business Practice Location Address Fax Number:
215-729-8202
Provider Enumeration Date:
09/05/2025