Provider First Line Business Practice Location Address:
445 FAIRMOUNT AVE
Provider Second Line Business Practice Location Address:
1 ST FLOOR
Provider Business Practice Location Address City Name:
PHILADELPHIA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19123-2822
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-925-5661
Provider Business Practice Location Address Fax Number:
215-925-5531
Provider Enumeration Date:
01/25/2007