Provider First Line Business Practice Location Address:
2402 MAIN STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BAKER
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70714
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
225-778-1567
Provider Business Practice Location Address Fax Number:
225-771-1520
Provider Enumeration Date:
10/02/2006