Provider First Line Business Practice Location Address:
34TH STREET & CIVIC CTR BLVD
Provider Second Line Business Practice Location Address:
SUITE 9328
Provider Business Practice Location Address City Name:
PHILADELPHIA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19104
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-590-1858
Provider Business Practice Location Address Fax Number:
215-977-8351
Provider Enumeration Date:
10/17/2006