Provider First Line Business Practice Location Address:
4600 ROOSEVELT BLVD
Provider Second Line Business Practice Location Address:
A-3
Provider Business Practice Location Address City Name:
PHILADELPHIA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19124-2340
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-533-2595
Provider Business Practice Location Address Fax Number:
215-535-2519
Provider Enumeration Date:
12/02/2015