Provider First Line Business Practice Location Address:
4660 PORTLAND RD NE
Provider Second Line Business Practice Location Address:
SUITE 107
Provider Business Practice Location Address City Name:
SALEM
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97305-1684
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-390-6992
Provider Business Practice Location Address Fax Number:
503-390-6992
Provider Enumeration Date:
12/13/2006