Provider First Line Business Practice Location Address: 
1634 FARRINGTON RD
    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: 
19151-2714
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
215-915-3156
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
11/20/2013