Provider First Line Business Practice Location Address:
2320 FAIRMOUNT 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:
19130-2519
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-232-5262
Provider Business Practice Location Address Fax Number:
215-232-5149
Provider Enumeration Date:
11/30/2020