Provider First Line Business Practice Location Address: 
6604 FRANKFORD AVE
    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: 
19135-2509
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
215-266-8844
    Provider Business Practice Location Address Fax Number: 
856-245-7764
    Provider Enumeration Date: 
07/13/2011