Provider First Line Business Practice Location Address:
2200 MICHENER STREET
Provider Second Line Business Practice Location Address:
SUITE 18
Provider Business Practice Location Address City Name:
PHILADELPHIA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19115-3474
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-552-0006
Provider Business Practice Location Address Fax Number:
215-673-1666
Provider Enumeration Date:
03/02/2007