Provider First Line Business Practice Location Address: 
1217 SPRING GARDEN ST
    Provider Second Line Business Practice Location Address: 
STE #1
    Provider Business Practice Location Address City Name: 
PHILADELPHIA
    Provider Business Practice Location Address State Name: 
PA
    Provider Business Practice Location Address Postal Code: 
19123-3212
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
215-769-3561
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
11/10/2011