Provider First Line Business Practice Location Address:
4719 HORROCKS 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:
19124-2936
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-878-2198
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/17/2026