Provider First Line Business Practice Location Address:
4522 BALTIMORE 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:
19143-3705
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
267-225-4223
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/09/2025