Provider First Line Business Practice Location Address:
8200 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:
19152-2519
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-338-4967
Provider Business Practice Location Address Fax Number:
215-338-2437
Provider Enumeration Date:
06/27/2021