Provider First Line Business Practice Location Address:
1100 22ND ST SE
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:
97302-6558
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-967-6771
Provider Business Practice Location Address Fax Number:
503-385-8421
Provider Enumeration Date:
11/22/2005