Provider First Line Business Practice Location Address:
2032 S FRAZIER 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:
19143-5618
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
267-736-9099
Provider Business Practice Location Address Fax Number:
186-647-2140
Provider Enumeration Date:
03/19/2009