Provider First Line Business Practice Location Address:
1511 CARPENTER 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:
19146-2110
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
267-679-8198
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/24/2011