Provider First Line Business Practice Location Address:
1497 LANCASTER 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:
97301-1961
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-588-1155
Provider Business Practice Location Address Fax Number:
503-589-1155
Provider Enumeration Date:
06/12/2013