Provider First Line Business Practice Location Address:
2557 S 69TH 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:
19142-2110
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-939-5638
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/02/2014