Provider First Line Business Practice Location Address:
1718 LE ROY AVE
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:
94709-1116
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
602-430-8306
Provider Business Practice Location Address Fax Number:
917-591-7417
Provider Enumeration Date:
10/17/2012