Provider First Line Business Practice Location Address: 
7300 OLD YORK RD
    Provider Second Line Business Practice Location Address: 
211
    Provider Business Practice Location Address City Name: 
ELKINS PARK
    Provider Business Practice Location Address State Name: 
PA
    Provider Business Practice Location Address Postal Code: 
19027-3037
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
215-782-1606
    Provider Business Practice Location Address Fax Number: 
215-782-1605
    Provider Enumeration Date: 
09/09/2009