Provider First Line Business Practice Location Address:
620 12TH 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:
97301-4001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-327-4396
Provider Business Practice Location Address Fax Number:
503-255-1542
Provider Enumeration Date:
07/19/2007