Provider First Line Business Practice Location Address:
6100 CASTOR 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:
19149-3215
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-744-6061
Provider Business Practice Location Address Fax Number:
215-000-0000
Provider Enumeration Date:
11/23/2005