Provider First Line Business Practice Location Address:
10111 N CANTERBURY RD
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:
19114-1113
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
267-230-8312
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/24/2015