Provider First Line Business Practice Location Address:
1608 JIMMIE DAVIS HWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BOSSIER CITY
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71112-4559
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-747-2510
Provider Business Practice Location Address Fax Number:
318-742-3727
Provider Enumeration Date:
12/06/2005