Provider First Line Business Practice Location Address:
413 LYCEUM AVE
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:
19128-3418
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-482-9410
Provider Business Practice Location Address Fax Number:
215-482-6353
Provider Enumeration Date:
07/22/2008