Provider First Line Business Practice Location Address:
6038 WISSAHICKON AVE
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:
19144-4905
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-844-7566
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/20/2006