Provider First Line Business Practice Location Address:
3800 HAVERFORD AVE.
Provider Second Line Business Practice Location Address:
1ST FL.
Provider Business Practice Location Address City Name:
PHILADELPHIA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19104
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-432-9115
Provider Business Practice Location Address Fax Number:
484-453-8112
Provider Enumeration Date:
12/28/2012