Provider First Line Business Practice Location Address:
289 E ELLENDALE
Provider Second Line Business Practice Location Address:
SUITE 503
Provider Business Practice Location Address City Name:
DALLAS
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97338
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-623-8826
Provider Business Practice Location Address Fax Number:
503-623-8739
Provider Enumeration Date:
12/28/2006