Provider First Line Business Practice Location Address:
2546 S BROAD ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PHILADELPHIA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19145-4638
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-755-1001
Provider Business Practice Location Address Fax Number:
215-755-1406
Provider Enumeration Date:
05/14/2012