Provider First Line Business Practice Location Address:
BROAD AND VINE ST S
Provider Second Line Business Practice Location Address:
MS 206
Provider Business Practice Location Address City Name:
PHILADELPHIA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19102
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-762-1808
Provider Business Practice Location Address Fax Number:
215-762-2350
Provider Enumeration Date:
10/21/2005