Provider First Line Business Practice Location Address:
6404 ROOSEVELT BLVD
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:
19149-2943
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-743-3700
Provider Business Practice Location Address Fax Number:
215-743-3706
Provider Enumeration Date:
11/15/2006