Provider First Line Business Practice Location Address:
410 E ELLENDALE AVE
Provider Second Line Business Practice Location Address:
STE 2
Provider Business Practice Location Address City Name:
DALLAS
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97338-3052
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-623-8151
Provider Business Practice Location Address Fax Number:
503-623-8185
Provider Enumeration Date:
06/08/2006