Provider First Line Business Practice Location Address:
4641 ROOSEVELT BLVD
Provider Second Line Business Practice Location Address:
ORLEANS BLDG
Provider Business Practice Location Address City Name:
PHILADELPHIA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19124-2343
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-831-2836
Provider Business Practice Location Address Fax Number:
215-831-2929
Provider Enumeration Date:
10/08/2012