Provider First Line Business Practice Location Address:
21 ASHMEAD PL N
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:
19144-2916
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
267-375-9131
Provider Business Practice Location Address Fax Number:
267-787-1142
Provider Enumeration Date:
01/31/2013