Provider First Line Business Practice Location Address:
1455 E. BERT KOUNS
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SHREVEPORT
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71105
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-798-4422
Provider Business Practice Location Address Fax Number:
318-798-4412
Provider Enumeration Date:
08/27/2007