Provider First Line Business Practice Location Address:
6044 CASTOR AVE
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
PHILADELPHIA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19149-3205
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-535-5616
Provider Business Practice Location Address Fax Number:
215-535-5618
Provider Enumeration Date:
06/23/2009