Provider First Line Business Practice Location Address: 
1001 BALTIMORE PIKE STE 109
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
SPRINGFIELD
    Provider Business Practice Location Address State Name: 
PA
    Provider Business Practice Location Address Postal Code: 
19064-2852
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
610-690-1776
    Provider Business Practice Location Address Fax Number: 
610-690-1777
    Provider Enumeration Date: 
07/14/2011