Provider First Line Business Practice Location Address:
1655 CAPITOL ST NE
Provider Second Line Business Practice Location Address:
SUITE #9
Provider Business Practice Location Address City Name:
SALEM
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97303-6445
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-588-8167
Provider Business Practice Location Address Fax Number:
503-588-8167
Provider Enumeration Date:
10/31/2005