Provider First Line Business Practice Location Address:
501 ORTEGA ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAN FRANCISCO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94122-4623
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
508-504-6045
Provider Business Practice Location Address Fax Number:
415-712-0027
Provider Enumeration Date:
07/09/2025