Provider First Line Business Practice Location Address:
1245 EDGEWATER ST NW
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:
97304-4049
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-588-5816
Provider Business Practice Location Address Fax Number:
503-588-5803
Provider Enumeration Date:
01/31/2007