Provider First Line Business Practice Location Address:
4485 E THOMPSON ST
Provider Second Line Business Practice Location Address:
SUITE 1
Provider Business Practice Location Address City Name:
PHILADELPHIA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19137-1630
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-831-5147
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/15/2006