Provider First Line Business Practice Location Address:
3910 N POWELTON AVE
Provider Second Line Business Practice Location Address:
2ND FLR
Provider Business Practice Location Address City Name:
PHILADELPHIA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19104-2640
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-662-9008
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/12/2006