Provider First Line Business Practice Location Address:
269 S 52ND 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:
19139-4108
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
267-292-4114
Provider Business Practice Location Address Fax Number:
267-292-4152
Provider Enumeration Date:
06/21/2017