Provider First Line Business Practice Location Address:
4792 PORTLAND RD NE
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:
97305-3920
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-393-2142
Provider Business Practice Location Address Fax Number:
503-393-2521
Provider Enumeration Date:
03/06/2013