Provider First Line Business Practice Location Address:
2505 S BROAD ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PHILA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19148-4309
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-551-3340
Provider Business Practice Location Address Fax Number:
215-551-3320
Provider Enumeration Date:
09/21/2007