Provider First Line Business Practice Location Address: 
106 N HILLS AVE
    Provider Second Line Business Practice Location Address: 
1ST FLOOR
    Provider Business Practice Location Address City Name: 
GLENSIDE
    Provider Business Practice Location Address State Name: 
PA
    Provider Business Practice Location Address Postal Code: 
19038-1607
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
215-885-5200
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
06/28/2012