Provider First Line Business Practice Location Address:
1144 LOCUST STREET
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:
19107-6797
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-542-0430
Provider Business Practice Location Address Fax Number:
215-351-5595
Provider Enumeration Date:
08/22/2008