Provider First Line Business Practice Location Address:
6410A RISING SUN 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:
19111-5229
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-342-6777
Provider Business Practice Location Address Fax Number:
215-722-1259
Provider Enumeration Date:
01/13/2011