Provider First Line Business Practice Location Address:
4623 SPRUCE 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:
19139-4542
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-474-6100
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/23/2009