Provider First Line Business Practice Location Address:
699 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:
97304-3834
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-428-5073
Provider Business Practice Location Address Fax Number:
503-428-5077
Provider Enumeration Date:
10/17/2023