Provider First Line Business Practice Location Address:
9251 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:
19114-2205
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-464-6922
Provider Business Practice Location Address Fax Number:
215-464-6923
Provider Enumeration Date:
05/24/2006