Provider First Line Business Practice Location Address:
324 S 56TH STREET
Provider Second Line Business Practice Location Address:
COMM
Provider Business Practice Location Address City Name:
PHILADELPHIA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19143
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
267-930-2274
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/07/2023