Provider First Line Business Practice Location Address: 
351 N SUMNEYTOWN PIKE
    Provider Second Line Business Practice Location Address: 
MAIL STOP UG4D-72
    Provider Business Practice Location Address City Name: 
NORTH WALES
    Provider Business Practice Location Address State Name: 
PA
    Provider Business Practice Location Address Postal Code: 
19454-2505
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
267-305-5994
    Provider Business Practice Location Address Fax Number: 
267-305-6537
    Provider Enumeration Date: 
08/23/2006