Provider First Line Business Practice Location Address:
704 W GIRARD AVE
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:
19123-1313
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-992-2050
Provider Business Practice Location Address Fax Number:
866-562-1376
Provider Enumeration Date:
07/26/2013