Provider First Line Business Practice Location Address:
5501 OLD YORK RD
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:
19141-3018
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-456-7890
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/02/2015