Provider First Line Business Practice Location Address:
2312 ELLSWORTH ST
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:
94704-1562
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
916-892-9724
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/20/2025