Provider First Line Business Practice Location Address:
1143 LIBERTY 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:
97301-1047
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-588-5828
Provider Business Practice Location Address Fax Number:
503-361-0383
Provider Enumeration Date:
04/01/2008