Provider First Line Business Practice Location Address:
178 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:
503-623-8334
Provider Business Practice Location Address Fax Number:
503-623-7077
Provider Enumeration Date:
06/06/2011