Provider First Line Business Practice Location Address:
3225 STATE STREET
Provider Second Line Business Practice Location Address:
ROOM 249
Provider Business Practice Location Address City Name:
SALEM
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97301
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-584-2284
Provider Business Practice Location Address Fax Number:
503-584-2293
Provider Enumeration Date:
06/04/2008