Provider First Line Business Practice Location Address:
5119 ROOSEVELT BLVD
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:
19124-1744
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-831-1598
Provider Business Practice Location Address Fax Number:
267-343-7116
Provider Enumeration Date:
08/26/2014