Provider First Line Business Practice Location Address:
1160 WALLACE RD NW
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:
97304-3116
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-315-4001
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/14/2008