Provider First Line Business Practice Location Address:
120 GLEN EDEN AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OAKLAND
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94611-4319
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
510-433-7132
Provider Business Practice Location Address Fax Number:
510-428-9042
Provider Enumeration Date:
03/15/2011