Provider First Line Business Practice Location Address:
182 SW ACADEMY
Provider Second Line Business Practice Location Address:
SUITE 304
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:
503-623-9289
Provider Business Practice Location Address Fax Number:
503-831-1726
Provider Enumeration Date:
07/09/2006