Provider First Line Business Practice Location Address:
910 CAPITOL ST NE
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
SALEM
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97301-1201
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-391-2979
Provider Business Practice Location Address Fax Number:
503-581-8389
Provider Enumeration Date:
05/15/2008