Provider First Line Business Practice Location Address:
931 CLINTON STREET
Provider Second Line Business Practice Location Address:
SUITE 104
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:
215-931-0371
Provider Business Practice Location Address Fax Number:
215-931-0371
Provider Enumeration Date:
04/17/2007