Provider First Line Business Practice Location Address:
1802 FRANKFORD 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:
19125-2403
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
267-687-7562
Provider Business Practice Location Address Fax Number:
267-687-7703
Provider Enumeration Date:
12/14/2012