Provider First Line Business Practice Location Address:
715 N BROAD ST
Provider Second Line Business Practice Location Address:
RED SHIELD FAMILY RESIDENCE
Provider Business Practice Location Address City Name:
PHILADELPHIA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19123
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-787-2897
Provider Business Practice Location Address Fax Number:
215-787-2964
Provider Enumeration Date:
01/02/2007