Provider First Line Business Practice Location Address:
608 S 16TH 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:
19146-1503
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
510-501-7632
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/29/2009