Provider First Line Business Practice Location Address:
16 OLD ASHTON RD
Provider Second Line Business Practice Location Address:
SUITE 1
Provider Business Practice Location Address City Name:
PHILA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19152-1661
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-613-5069
Provider Business Practice Location Address Fax Number:
215-613-6809
Provider Enumeration Date:
07/28/2006