Provider First Line Business Practice Location Address:
34TH STREET AND CIVIC CENTER BLVD
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:
19104-4399
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
267-426-7148
Provider Business Practice Location Address Fax Number:
215-590-5171
Provider Enumeration Date:
05/30/2006