Provider First Line Business Practice Location Address:
1614 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:
19145-4537
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
267-966-2111
Provider Business Practice Location Address Fax Number:
215-689-4141
Provider Enumeration Date:
06/26/2015