Provider First Line Business Practice Location Address: 
21524 FOOTHILL BLVD
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
HAYWARD
    Provider Business Practice Location Address State Name: 
CA
    Provider Business Practice Location Address Postal Code: 
94541-2111
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
510-461-0331
    Provider Business Practice Location Address Fax Number: 
510-537-6339
    Provider Enumeration Date: 
09/20/2006