Provider First Line Business Practice Location Address:
112 SOUTH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PHILADELPHIA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19147-2419
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-923-8688
Provider Business Practice Location Address Fax Number:
267-247-0481
Provider Enumeration Date:
02/20/2014