Provider First Line Business Practice Location Address:
161 HIGH ST SE
Provider Second Line Business Practice Location Address:
SUITE 206 C
Provider Business Practice Location Address City Name:
SALEM
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97301-3660
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-364-4039
Provider Business Practice Location Address Fax Number:
503-364-4059
Provider Enumeration Date:
10/23/2006