Provider First Line Business Practice Location Address:
1811 E BERT KOUN LOOP
Provider Second Line Business Practice Location Address:
SUITE 130
Provider Business Practice Location Address City Name:
SHREVEPORT
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71105-5740
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-212-2929
Provider Business Practice Location Address Fax Number:
318-212-2924
Provider Enumeration Date:
06/21/2006