Provider Demographics
NPI:1659682870
Name:CEDARLEAF, MARK (LMT)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:
Last Name:CEDARLEAF
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:353 GLEN CREEK RD NW APT 16
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97304-3091
Mailing Address - Country:US
Mailing Address - Phone:503-375-2989
Mailing Address - Fax:
Practice Address - Street 1:705 12TH ST SE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-4004
Practice Address - Country:US
Practice Address - Phone:503-375-2989
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-23
Last Update Date:2010-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR7983172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist