Provider First Line Business Practice Location Address:
280 COURT ST NE
Provider Second Line Business Practice Location Address:
STES #205 & #210
Provider Business Practice Location Address City Name:
SALEM
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97301-3443
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-581-0808
Provider Business Practice Location Address Fax Number:
503-371-0991
Provider Enumeration Date:
12/27/2005