Provider First Line Business Practice Location Address:
2212 FITZWATER 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:
19146-1708
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
717-818-7170
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/17/2026