Provider First Line Business Practice Location Address:
4407 MAIN 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:
19127-1311
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-487-2711
Provider Business Practice Location Address Fax Number:
215-487-3647
Provider Enumeration Date:
07/30/2008