Provider First Line Business Practice Location Address:
138 W 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:
97338-1408
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-831-6006
Provider Business Practice Location Address Fax Number:
503-831-6008
Provider Enumeration Date:
06/21/2006