Provider First Line Business Practice Location Address:
2226 S BROAD ST
Provider Second Line Business Practice Location Address:
SUITE 1
Provider Business Practice Location Address City Name:
PHILA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19145-3947
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-334-5967
Provider Business Practice Location Address Fax Number:
215-334-5967
Provider Enumeration Date:
07/21/2006