Provider First Line Business Practice Location Address:
1118 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:
97302-2811
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-952-6781
Provider Business Practice Location Address Fax Number:
503-967-7591
Provider Enumeration Date:
12/02/2014