Provider First Line Business Practice Location Address:
5555 WISSAHICKON AVE
Provider Second Line Business Practice Location Address:
SUITE L-95
Provider Business Practice Location Address City Name:
PHILADELPHIA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19144-4555
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-848-2023
Provider Business Practice Location Address Fax Number:
215-843-8240
Provider Enumeration Date:
05/29/2006