Provider First Line Business Practice Location Address:
2630 HOLME AVE
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:
19152-3004
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
267-339-3500
Provider Business Practice Location Address Fax Number:
267-339-3763
Provider Enumeration Date:
07/08/2006