Provider First Line Business Practice Location Address:
1555 E WADSWORTH AVE
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:
19150-1617
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
267-323-2778
Provider Business Practice Location Address Fax Number:
267-323-2774
Provider Enumeration Date:
06/01/2022