Provider First Line Business Practice Location Address:
1357 5TH 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:
94607-1804
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
510-459-0348
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/22/2025