Provider First Line Business Practice Location Address:
182 SW ACADEMY ST
Provider Second Line Business Practice Location Address:
COUNTY OF POLK, SUITE 220
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:
503-623-9317
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/12/2013