Provider First Line Business Practice Location Address:
762 HIGH 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:
97301-2440
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-364-7502
Provider Business Practice Location Address Fax Number:
503-364-1254
Provider Enumeration Date:
08/30/2005