Provider First Line Business Practice Location Address:
1925 VINE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BERKELEY
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94709-2031
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
510-847-0630
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/19/2026