Provider First Line Business Practice Location Address:
1124 S 53RD 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:
19143
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-626-5378
Provider Business Practice Location Address Fax Number:
267-292-5669
Provider Enumeration Date:
07/19/2011