Provider First Line Business Practice Location Address:
9908 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:
19115-1705
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-673-9260
Provider Business Practice Location Address Fax Number:
215-673-9254
Provider Enumeration Date:
05/14/2010