Provider First Line Business Practice Location Address:
211 E. ELLENDALE SUITE #7
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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-831-5831
Provider Business Practice Location Address Fax Number:
503-623-2505
Provider Enumeration Date:
05/22/2007