Provider First Line Business Practice Location Address:
4523-25 BALTIMORE AVE
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:
19143-1914
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-222-3349
Provider Business Practice Location Address Fax Number:
215-222-4044
Provider Enumeration Date:
11/12/2021