Provider First Line Business Practice Location Address:
908 N 3RD ST SIDE B
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:
19123-2206
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
267-570-3603
Provider Business Practice Location Address Fax Number:
267-574-9316
Provider Enumeration Date:
10/20/2021