Provider First Line Business Practice Location Address: 
727 WELSH RD
    Provider Second Line Business Practice Location Address: 
SUITE 103
    Provider Business Practice Location Address City Name: 
HUNTINGDON VALLEY
    Provider Business Practice Location Address State Name: 
PA
    Provider Business Practice Location Address Postal Code: 
19006-6357
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
215-947-7550
    Provider Business Practice Location Address Fax Number: 
215-947-0590
    Provider Enumeration Date: 
01/31/2006