Provider First Line Business Practice Location Address:
1104 SHATTUCK AVE
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:
94707-2610
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
510-525-9215
Provider Business Practice Location Address Fax Number:
510-525-4651
Provider Enumeration Date:
10/19/2006