Provider First Line Business Practice Location Address:
3300 GRANT AVE STE 21
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PHILADELPHIA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19114-2632
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-335-9090
Provider Business Practice Location Address Fax Number:
215-333-5225
Provider Enumeration Date:
01/20/2015