Provider First Line Business Practice Location Address:
210 WEST ELLENDALE AVE.
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
DALLAS
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97338-0000
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-623-2433
Provider Business Practice Location Address Fax Number:
503-623-2196
Provider Enumeration Date:
05/13/2009