Provider First Line Business Practice Location Address:
1600 W GIRARD AVE
Provider Second Line Business Practice Location Address:
2ND FLOOR
Provider Business Practice Location Address City Name:
PHILADELPHIA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19130-1615
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-787-9503
Provider Business Practice Location Address Fax Number:
215-787-9164
Provider Enumeration Date:
05/09/2008