Provider First Line Business Practice Location Address:
5501 OLD YORK RD
Provider Second Line Business Practice Location Address:
MOSS 1
Provider Business Practice Location Address City Name:
PHILADELPHIA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19141-3098
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-517-8665
Provider Business Practice Location Address Fax Number:
215-581-3934
Provider Enumeration Date:
06/09/2006