Provider First Line Business Practice Location Address:
2821 ISLAND AVE
Provider Second Line Business Practice Location Address:
SUITE D& E
Provider Business Practice Location Address City Name:
PHILADELPHIA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19153-2300
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-863-6110
Provider Business Practice Location Address Fax Number:
610-863-6111
Provider Enumeration Date:
10/18/2005