Provider First Line Business Practice Location Address:
3110 GRANT AVE
Provider Second Line Business Practice Location Address:
ROOMS 15-18
Provider Business Practice Location Address City Name:
PHILADELPHIA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19114-2542
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-464-4550
Provider Business Practice Location Address Fax Number:
215-464-4880
Provider Enumeration Date:
07/20/2007