Provider First Line Business Practice Location Address:
1332 ELBRIDGE 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:
19111-5511
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
267-596-0725
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/21/2020