Provider First Line Business Practice Location Address:
2212 JEFFERSON 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:
94703-1618
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
510-491-5509
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/09/2023