Provider First Line Business Practice Location Address:
2047 WALLACE ST
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:
19130-3221
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-232-6216
Provider Business Practice Location Address Fax Number:
215-787-9911
Provider Enumeration Date:
06/18/2009