Provider First Line Business Practice Location Address:
3419 WALNUT 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:
19104-3410
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-386-5953
Provider Business Practice Location Address Fax Number:
215-386-3508
Provider Enumeration Date:
07/31/2006