Provider First Line Business Practice Location Address:
702 CHURCH ST NE
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
SALEM
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97301-2404
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-540-4052
Provider Business Practice Location Address Fax Number:
503-540-4054
Provider Enumeration Date:
12/10/2008