Provider First Line Business Practice Location Address:
2605 12TH PL 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:
97302-2576
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-585-4281
Provider Business Practice Location Address Fax Number:
503-585-7427
Provider Enumeration Date:
07/01/2005