Provider First Line Business Practice Location Address:
3400 CIVIC CENTER BOULEVARD
Provider Second Line Business Practice Location Address:
EAST PAVILION, 2ND FLOOR
Provider Business Practice Location Address City Name:
PHILADELPHIA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19104-4306
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-615-4949
Provider Business Practice Location Address Fax Number:
215-615-0829
Provider Enumeration Date:
12/13/2006