Provider First Line Business Practice Location Address:
1140 BAXTER RD 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:
97306-1528
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-602-0545
Provider Business Practice Location Address Fax Number:
503-408-5021
Provider Enumeration Date:
11/02/2012