Provider First Line Business Practice Location Address:
6212 WALNUT 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:
19139-3706
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-951-7630
Provider Business Practice Location Address Fax Number:
215-476-0250
Provider Enumeration Date:
08/28/2006