Provider First Line Business Practice Location Address:
1415 NORTH BROAD STREET
Provider Second Line Business Practice Location Address:
SUITE 224 BROAD STREET HEALTH CENTER
Provider Business Practice Location Address City Name:
PHILADELPHIA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19122-3323
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-235-7944
Provider Business Practice Location Address Fax Number:
215-235-3361
Provider Enumeration Date:
11/20/2007