Provider First Line Business Practice Location Address:
1487 MAIN ST
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:
97338-2520
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-623-4230
Provider Business Practice Location Address Fax Number:
503-623-4230
Provider Enumeration Date:
11/19/2008