Provider First Line Business Practice Location Address:
6124 W JEFFERSON 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:
19151-3902
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-477-0878
Provider Business Practice Location Address Fax Number:
215-477-1523
Provider Enumeration Date:
04/20/2010