Provider First Line Business Practice Location Address:
2478 13TH 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:
97302-2546
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-362-2481
Provider Business Practice Location Address Fax Number:
503-371-7803
Provider Enumeration Date:
09/01/2005