Provider First Line Business Practice Location Address:
3900 SPRUCE ST
Provider Second Line Business Practice Location Address:
VHUP 2036
Provider Business Practice Location Address City Name:
PHILADELPHIA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19104-4113
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-573-5693
Provider Business Practice Location Address Fax Number:
215-573-4617
Provider Enumeration Date:
09/15/2014