Provider First Line Business Practice Location Address:
11924 JUSTICE AVE.
Provider Second Line Business Practice Location Address:
STE. A
Provider Business Practice Location Address City Name:
BATON ROUGE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70816-2372
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
225-291-6647
Provider Business Practice Location Address Fax Number:
225-291-9463
Provider Enumeration Date:
09/07/2006