Provider First Line Business Practice Location Address: 
2302 N BROAD ST
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
LANSDALE
    Provider Business Practice Location Address State Name: 
PA
    Provider Business Practice Location Address Postal Code: 
19446-0749
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
215-822-1365
    Provider Business Practice Location Address Fax Number: 
215-822-2527
    Provider Enumeration Date: 
09/15/2005