Provider First Line Business Practice Location Address:
34TH & CIVIC CENTER BLVD
Provider Second Line Business Practice Location Address:
2 MAIN BLDG
Provider Business Practice Location Address City Name:
PHILADELPHIA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19104
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
267-426-4078
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/08/2007