Provider First Line Business Practice Location Address:
182 SW ACADEMY STREET
Provider Second Line Business Practice Location Address:
SUITE 302
Provider Business Practice Location Address City Name:
DALLAS
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97338-1922
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-623-8175
Provider Business Practice Location Address Fax Number:
503-831-3499
Provider Enumeration Date:
07/10/2006