Provider First Line Business Practice Location Address:
7602 CENTRAL AVE
Provider Second Line Business Practice Location Address:
SUITE 201
Provider Business Practice Location Address City Name:
PHILADELPHIA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19111-2443
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-728-7558
Provider Business Practice Location Address Fax Number:
215-728-7552
Provider Enumeration Date:
01/15/2007