Provider First Line Business Practice Location Address:
34TH STREET & CIVIC CENTER BOULEVARD
Provider Second Line Business Practice Location Address:
WOOD AMBULATORY CARE BUILDING 5TH 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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
267-226-9268
Provider Business Practice Location Address Fax Number:
215-590-9045
Provider Enumeration Date:
04/20/2011