Provider First Line Business Practice Location Address:
1594 EDGEWATER STREET NW
Provider Second Line Business Practice Location Address:
SUITE 190
Provider Business Practice Location Address City Name:
SALEM
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97304-4656
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-779-2119
Provider Business Practice Location Address Fax Number:
503-779-1195
Provider Enumeration Date:
05/24/2006