Provider First Line Business Practice Location Address:
2900 W QUEEN LN
Provider Second Line Business Practice Location Address:
SUITE 221H
Provider Business Practice Location Address City Name:
PHILADELPHIA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19129-1033
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-991-8532
Provider Business Practice Location Address Fax Number:
215-843-5495
Provider Enumeration Date:
10/13/2005