Provider First Line Business Practice Location Address:
34TH AND CIVIC CENTER BLVD
Provider Second Line Business Practice Location Address:
8 SOUTH
Provider Business Practice Location Address City Name:
PHILADELPHIA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19104-4399
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-590-3174
Provider Business Practice Location Address Fax Number:
267-426-7063
Provider Enumeration Date:
07/25/2007