Provider First Line Business Practice Location Address:
2110 VINE ST STE B
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:
94709-1577
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
510-540-5555
Provider Business Practice Location Address Fax Number:
510-548-3999
Provider Enumeration Date:
04/19/2019