Provider First Line Business Practice Location Address:
2200 E ELLENDALE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DALLAS
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97338-9353
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-623-5588
Provider Business Practice Location Address Fax Number:
503-623-4729
Provider Enumeration Date:
12/01/2010