Provider First Line Business Practice Location Address:
3035 W DIAMOND 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:
19121-1142
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-680-7259
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/05/2007