Provider First Line Business Practice Location Address: 
2114 DIVISADERO ST
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
SAN FRANCISCO
    Provider Business Practice Location Address State Name: 
CA
    Provider Business Practice Location Address Postal Code: 
94115-2127
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
415-922-4094
    Provider Business Practice Location Address Fax Number: 
415-346-8170
    Provider Enumeration Date: 
06/13/2006