Provider First Line Business Practice Location Address:
3003 FRUITVALE 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:
94602-2110
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
510-436-0823
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/01/2025