Provider First Line Business Practice Location Address:
12401 ACADEMY RD STE 201
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:
19154-1934
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-637-3121
Provider Business Practice Location Address Fax Number:
215-437-7738
Provider Enumeration Date:
11/06/2006