Provider First Line Business Practice Location Address:
2216 TEAKWOOD AVE 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:
97304-1344
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-684-0311
Provider Business Practice Location Address Fax Number:
503-689-8088
Provider Enumeration Date:
10/04/2010