Provider First Line Business Practice Location Address:
1544 COMMERCIAL ST 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:
97302-4310
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-362-7064
Provider Business Practice Location Address Fax Number:
503-362-7047
Provider Enumeration Date:
10/28/2005