Provider First Line Business Practice Location Address:
2115 E DAKOTA 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:
19125-2053
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
917-715-2744
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/16/2022