Provider First Line Business Practice Location Address:
1316 W ONTARIO 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:
19140-5220
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-707-2400
Provider Business Practice Location Address Fax Number:
215-707-4034
Provider Enumeration Date:
05/24/2016