Provider First Line Business Practice Location Address:
5915 N BROAD ST
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:
19141-1801
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-424-1966
Provider Business Practice Location Address Fax Number:
215-549-2499
Provider Enumeration Date:
01/02/2008