Provider First Line Business Practice Location Address:
1296 COMMERCIAL ST SE
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
SALEM
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97302-4204
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-585-4282
Provider Business Practice Location Address Fax Number:
503-375-9534
Provider Enumeration Date:
07/18/2005