Provider First Line Business Practice Location Address:
1340 CHEMEKETA ST NE
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:
97301-4151
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-390-1009
Provider Business Practice Location Address Fax Number:
503-588-9996
Provider Enumeration Date:
03/28/2007