Provider First Line Business Practice Location Address:
608 SE JEFFERSON 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:
97338-2024
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-623-2225
Provider Business Practice Location Address Fax Number:
503-623-2425
Provider Enumeration Date:
11/30/2006