Provider First Line Business Practice Location Address:
6300 THEODORE ST FL 1
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:
19142-3116
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
267-582-2920
Provider Business Practice Location Address Fax Number:
215-330-4499
Provider Enumeration Date:
01/15/2022