Provider First Line Business Practice Location Address:
1505 WATER ST NE
Provider Second Line Business Practice Location Address:
SUITE 5
Provider Business Practice Location Address City Name:
SALEM
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97303-6967
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-363-2430
Provider Business Practice Location Address Fax Number:
503-363-2195
Provider Enumeration Date:
04/19/2007