Provider First Line Business Practice Location Address:
1801 VINE ST
Provider Second Line Business Practice Location Address:
ROOM 149-MG
Provider Business Practice Location Address City Name:
PHILADELPHIA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19103-1117
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-868-5160
Provider Business Practice Location Address Fax Number:
215-546-9564
Provider Enumeration Date:
01/27/2007