Provider First Line Business Practice Location Address:
2031 LOCUST ST
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:
19103-5611
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-564-4277
Provider Business Practice Location Address Fax Number:
215-563-9721
Provider Enumeration Date:
09/11/2008