Provider First Line Business Practice Location Address:
5313 OGDEN 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:
19139-1438
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-600-9477
Provider Business Practice Location Address Fax Number:
215-921-8499
Provider Enumeration Date:
04/23/2016