Provider First Line Business Practice Location Address:
1508 E WADSWORTH AVE
Provider Second Line Business Practice Location Address:
2C
Provider Business Practice Location Address City Name:
PHILADELPHIA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19150-1616
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-242-1890
Provider Business Practice Location Address Fax Number:
215-242-2692
Provider Enumeration Date:
07/19/2007