Provider First Line Business Practice Location Address:
322 S 56TH 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:
19143-1302
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
484-989-9811
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/30/2023