Provider First Line Business Practice Location Address:
2693 FRUITVALE AVE
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:
94601-2034
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
510-261-1412
Provider Business Practice Location Address Fax Number:
510-261-1414
Provider Enumeration Date:
10/22/2009