Provider First Line Business Practice Location Address:
132 S 10TH ST
Provider Second Line Business Practice Location Address:
SUITE 1099J
Provider Business Practice Location Address City Name:
PHILADELPHIA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19107
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-955-6028
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/23/2012