Provider First Line Business Practice Location Address:
5219 N LAWRENCE 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:
19120-3305
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
404-680-7896
Provider Business Practice Location Address Fax Number:
215-798-9848
Provider Enumeration Date:
08/31/2007