Provider First Line Business Practice Location Address:
4240 OLD YORK RD
Provider Second Line Business Practice Location Address:
SUITE 1A
Provider Business Practice Location Address City Name:
PHILADELPHIA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19140-2050
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-456-9007
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/16/2015