Provider First Line Business Practice Location Address: 
888 44TH ST
    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: 
94608-3402
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
415-244-1263
    Provider Business Practice Location Address Fax Number: 
510-655-3972
    Provider Enumeration Date: 
08/14/2006