Provider First Line Business Practice Location Address:
1815 SO BROAD 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:
19148
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-462-6229
Provider Business Practice Location Address Fax Number:
215-467-9080
Provider Enumeration Date:
08/30/2006