Provider First Line Business Practice Location Address:
3400 CIVIC CENTER BLVD
Provider Second Line Business Practice Location Address:
1ST FLOOR, SUITE 300 S
Provider Business Practice Location Address City Name:
PHILADELPHIA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19104-4306
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-662-2638
Provider Business Practice Location Address Fax Number:
215-349-5703
Provider Enumeration Date:
07/18/2005