Provider First Line Business Practice Location Address:
1326 SPRUCE ST
Provider Second Line Business Practice Location Address:
#1701
Provider Business Practice Location Address City Name:
PHILA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19107-5826
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-685-5460
Provider Business Practice Location Address Fax Number:
215-685-5467
Provider Enumeration Date:
11/14/2006