Provider First Line Business Practice Location Address: 
3400 STATE ST STE G704
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
SALEM
    Provider Business Practice Location Address State Name: 
OR
    Provider Business Practice Location Address Postal Code: 
97301-5105
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
503-378-7434
    Provider Business Practice Location Address Fax Number: 
503-362-2703
    Provider Enumeration Date: 
12/14/2005