Provider First Line Business Practice Location Address:
6628 WOODLAND AVENUE
Provider Second Line Business Practice Location Address:
LOWER LEVEL
Provider Business Practice Location Address City Name:
PHILADELPHIA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19142
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
267-254-4551
Provider Business Practice Location Address Fax Number:
215-739-1239
Provider Enumeration Date:
07/27/2010