Provider First Line Business Practice Location Address: 
704 W GIRARD 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: 
19123-1313
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
215-992-2050
    Provider Business Practice Location Address Fax Number: 
866-562-1376
    Provider Enumeration Date: 
07/26/2013