Provider First Line Business Practice Location Address:
1610 12TH ST 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:
97302-2821
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-316-6575
Provider Business Practice Location Address Fax Number:
541-210-8913
Provider Enumeration Date:
03/27/2024