Provider First Line Business Practice Location Address:
1601 WALNUT ST
Provider Second Line Business Practice Location Address:
SUITE 704 MED ARTS BLDG
Provider Business Practice Location Address City Name:
PHILADELPHIA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19102-2944
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-496-0481
Provider Business Practice Location Address Fax Number:
215-496-9887
Provider Enumeration Date:
04/23/2007