Provider First Line Business Practice Location Address: 
840 PENN AVENUE
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
WYOMISSING
    Provider Business Practice Location Address State Name: 
PA
    Provider Business Practice Location Address Postal Code: 
19610-3016
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
610-374-4097
    Provider Business Practice Location Address Fax Number: 
484-734-1303
    Provider Enumeration Date: 
09/27/2006