Provider First Line Business Practice Location Address: 
444 N 3RD ST
    Provider Second Line Business Practice Location Address: 
SUITE C-11
    Provider Business Practice Location Address City Name: 
PHILADELPHIA
    Provider Business Practice Location Address State Name: 
PA
    Provider Business Practice Location Address Postal Code: 
19123-4107
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
267-639-3394
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
02/26/2015