Provider First Line Business Practice Location Address:
5136 N 4TH 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:
19120-3337
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
267-423-5312
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/03/2021