Provider First Line Business Practice Location Address:
616 CRESCENT AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOCKPORT
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70374-2735
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
985-562-9140
Provider Business Practice Location Address Fax Number:
985-532-9205
Provider Enumeration Date:
08/03/2006