Provider First Line Business Practice Location Address:
501 S 54TH ST
Provider Second Line Business Practice Location Address:
SUITE 126
Provider Business Practice Location Address City Name:
PHILADELPHIA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19143-1900
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-748-9872
Provider Business Practice Location Address Fax Number:
215-748-9869
Provider Enumeration Date:
02/03/2006