Provider First Line Business Practice Location Address:
1064 47TH ST UNIT A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EMERYVILLE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94608-3316
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-850-5611
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/17/2026