Provider First Line Business Practice Location Address:
4641 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:
19124-2343
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-831-4600
Provider Business Practice Location Address Fax Number:
215-831-6984
Provider Enumeration Date:
11/10/2005