Provider First Line Business Practice Location Address:
150 KINGWOOD 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:
97304-4030
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-378-7526
Provider Business Practice Location Address Fax Number:
503-585-4278
Provider Enumeration Date:
10/17/2007