Provider First Line Business Practice Location Address:
1196 E WASHINGTON LN
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:
19138-1044
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-866-0200
Provider Business Practice Location Address Fax Number:
215-866-0201
Provider Enumeration Date:
10/24/2022