Provider First Line Business Practice Location Address: 
2228 6TH ST
    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: 
94710-2219
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
510-540-6267
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
12/04/2014