Provider First Line Business Practice Location Address:
561 FAIRTHORNE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PHILA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19128-2412
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-487-4164
Provider Business Practice Location Address Fax Number:
267-338-2272
Provider Enumeration Date:
01/27/2007