Provider First Line Business Practice Location Address:
1541 W PORTER 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:
19145-4453
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-598-2006
Provider Business Practice Location Address Fax Number:
267-861-0125
Provider Enumeration Date:
10/10/2023