Provider First Line Business Practice Location Address: 
700 SPRUCE STREET
    Provider Second Line Business Practice Location Address: 
SUITE 403
    Provider Business Practice Location Address City Name: 
PHILADELPHIA
    Provider Business Practice Location Address State Name: 
PA
    Provider Business Practice Location Address Postal Code: 
19106
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
215-829-6089
    Provider Business Practice Location Address Fax Number: 
215-829-3011
    Provider Enumeration Date: 
01/15/2008