Provider First Line Business Practice Location Address:
1100 WASHINGTON AVENUE,
Provider Second Line Business Practice Location Address:
UNIT 1A OF LOT C
Provider Business Practice Location Address City Name:
PHILADELPHIA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19147
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-218-3200
Provider Business Practice Location Address Fax Number:
215-218-3201
Provider Enumeration Date:
10/26/2011