Provider First Line Business Practice Location Address:
9140 ACADEMY ROAD
Provider Second Line Business Practice Location Address:
SUITE G
Provider Business Practice Location Address City Name:
PHILADELPHIA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19114
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-378-5162
Provider Business Practice Location Address Fax Number:
215-624-7955
Provider Enumeration Date:
12/09/2008