Provider First Line Business Practice Location Address:
11596 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:
19116-3032
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-677-8200
Provider Business Practice Location Address Fax Number:
215-969-2681
Provider Enumeration Date:
05/02/2006