Provider First Line Business Practice Location Address:
1300 W JEFFERSON ST
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
PHILADELPHIA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19122-3326
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-560-8893
Provider Business Practice Location Address Fax Number:
215-644-9043
Provider Enumeration Date:
06/22/2013