Provider First Line Business Practice Location Address:
246 W UPSAL ST
Provider Second Line Business Practice Location Address:
APT A404
Provider Business Practice Location Address City Name:
PHILADELPHIA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19119-3264
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-298-2002
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/24/2008