Provider First Line Business Practice Location Address:
2794 12TH ST SE
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:
97302-3159
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-566-8456
Provider Business Practice Location Address Fax Number:
503-931-9121
Provider Enumeration Date:
01/16/2008