Provider First Line Business Practice Location Address:
1420 LOCUST STREET
Provider Second Line Business Practice Location Address:
SUITE 120
Provider Business Practice Location Address City Name:
PHILADELPHIA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19102
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-732-9171
Provider Business Practice Location Address Fax Number:
215-545-0892
Provider Enumeration Date:
05/28/2008