Provider First Line Business Practice Location Address:
1116 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:
19147-1915
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-440-7701
Provider Business Practice Location Address Fax Number:
215-440-7702
Provider Enumeration Date:
07/12/2006