Provider First Line Business Practice Location Address:
1613 SOUTH BROAD ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PHILIDELPHIA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19148
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-389-2511
Provider Business Practice Location Address Fax Number:
215-389-0334
Provider Enumeration Date:
08/30/2006