Provider First Line Business Practice Location Address:
4190 CITY AVE
Provider Second Line Business Practice Location Address:
SUITE 315
Provider Business Practice Location Address City Name:
PHILADELPHIA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19131-1626
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-871-6337
Provider Business Practice Location Address Fax Number:
215-871-6347
Provider Enumeration Date:
11/16/2009