Provider First Line Business Practice Location Address:
112 N BROAD ST
Provider Second Line Business Practice Location Address:
RM 821
Provider Business Practice Location Address City Name:
PHILADELPHIA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19102-1512
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-568-0860
Provider Business Practice Location Address Fax Number:
215-568-0769
Provider Enumeration Date:
02/22/2010