Provider First Line Business Practice Location Address:
1332 POWELL ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EMERYVILLE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94608-2506
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
314-825-2238
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/23/2026