Provider First Line Business Practice Location Address:
2525 12TH ST SE STE 110
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:
97302-2153
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-364-3704
Provider Business Practice Location Address Fax Number:
503-399-9722
Provider Enumeration Date:
08/05/2006