Provider First Line Business Practice Location Address:
6410 A RISING SUN AVE
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:
19111-5229
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-876-0083
Provider Business Practice Location Address Fax Number:
215-278-4272
Provider Enumeration Date:
12/29/2016