Provider First Line Business Practice Location Address:
1420-22 CHESTNUT ST
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:
19102
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
267-514-1823
Provider Business Practice Location Address Fax Number:
267-514-1834
Provider Enumeration Date:
06/02/2008