Provider First Line Business Practice Location Address:
2509 S 4TH 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:
19148-4712
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-271-1080
Provider Business Practice Location Address Fax Number:
215-368-5254
Provider Enumeration Date:
11/29/2006