Provider First Line Business Practice Location Address:
6404 ROOSEVELT BLVD
Provider Second Line Business Practice Location Address:
2ND FLOOR
Provider Business Practice Location Address City Name:
PHILADELPHIA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19149-2943
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-831-1023
Provider Business Practice Location Address Fax Number:
215-831-1129
Provider Enumeration Date:
03/20/2008