Provider First Line Business Practice Location Address:
1255 WALLACE RD NW
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:
97304-3007
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-395-4101
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/24/2026