Provider First Line Business Practice Location Address:
350 30TH ST. #205
Provider Second Line Business Practice Location Address:
PROVIDER ENROLLMENT
Provider Business Practice Location Address City Name:
OAKLAND
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94609
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
510-444-0790
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/04/2006