Provider First Line Business Practice Location Address:
1501 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:
19150-1605
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
267-774-5629
Provider Business Practice Location Address Fax Number:
267-774-5639
Provider Enumeration Date:
11/11/2015