Provider First Line Business Practice Location Address:
1211 EDGEWATER ST. NW
Provider Second Line Business Practice Location Address:
SUITE 2
Provider Business Practice Location Address City Name:
SALEM
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97304-4073
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-391-7132
Provider Business Practice Location Address Fax Number:
503-296-5855
Provider Enumeration Date:
07/21/2008