Provider First Line Business Practice Location Address:
253 SO 10TH STREET
Provider Second Line Business Practice Location Address:
SUITE 201
Provider Business Practice Location Address City Name:
PHILADELPHIA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19107-5605
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-829-0170
Provider Business Practice Location Address Fax Number:
215-829-0173
Provider Enumeration Date:
11/01/2006