Provider First Line Business Practice Location Address:
2000 S LARRY 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:
19142-1142
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
484-461-2200
Provider Business Practice Location Address Fax Number:
484-450-4979
Provider Enumeration Date:
06/23/2015