Provider First Line Business Practice Location Address: 
350 30TH ST
    Provider Second Line Business Practice Location Address: 
SUITE 100
    Provider Business Practice Location Address City Name: 
OAKLAND
    Provider Business Practice Location Address State Name: 
CA
    Provider Business Practice Location Address Postal Code: 
94609-3424
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
510-204-8290
    Provider Business Practice Location Address Fax Number: 
510-273-8977
    Provider Enumeration Date: 
07/12/2006