Provider First Line Business Practice Location Address: 
4510 FRANKFORD AVE
    Provider Second Line Business Practice Location Address: 
2ND FLOOR
    Provider Business Practice Location Address City Name: 
PHILADELPHIA
    Provider Business Practice Location Address State Name: 
PA
    Provider Business Practice Location Address Postal Code: 
19124-3602
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
215-831-9882
    Provider Business Practice Location Address Fax Number: 
215-831-9887
    Provider Enumeration Date: 
12/21/2011