Provider First Line Business Practice Location Address:
3400 CIVIC CENTER BLVD
Provider Second Line Business Practice Location Address:
SUITE EAST PAVILION 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:
19104-5127
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-456-7890
Provider Business Practice Location Address Fax Number:
215-456-2482
Provider Enumeration Date:
08/03/2011