Provider First Line Business Practice Location Address:
209 N 4TH ST
Provider Second Line Business Practice Location Address:
C-1
Provider Business Practice Location Address City Name:
PHILADELPHIA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19106-1855
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-756-3979
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/29/2008