Provider First Line Business Practice Location Address:
3900 FORD ROAD
Provider Second Line Business Practice Location Address:
SUITE 12
Provider Business Practice Location Address City Name:
PHILA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19131-2001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-471-9620
Provider Business Practice Location Address Fax Number:
215-877-5551
Provider Enumeration Date:
01/09/2007