Provider First Line Business Practice Location Address:
1729 TEESDALE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PHILA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19111-3808
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
267-304-3576
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/06/2009