Provider First Line Business Practice Location Address:
693 12TH ST. SE.
Provider Second Line Business Practice Location Address:
SUITE #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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-383-1248
Provider Business Practice Location Address Fax Number:
503-217-6526
Provider Enumeration Date:
07/22/2022