Provider First Line Business Practice Location Address:
5050 PARKSIDE AVE
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:
19131-4751
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-390-1742
Provider Business Practice Location Address Fax Number:
815-768-2340
Provider Enumeration Date:
08/31/2006