Provider First Line Business Practice Location Address:
169 W LEHIGH 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:
19133-3832
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
267-858-4662
Provider Business Practice Location Address Fax Number:
267-858-4454
Provider Enumeration Date:
01/05/2015