Provider First Line Business Practice Location Address:
34TH STREET AND CIVIC CENTER BOULEVARD
Provider Second Line Business Practice Location Address:
SUITE 9329
Provider Business Practice Location Address City Name:
PHILADELPHIA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19104-4399
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-590-1867
Provider Business Practice Location Address Fax Number:
215-590-5824
Provider Enumeration Date:
06/13/2012