Provider First Line Business Practice Location Address:
5839 E KINGS HWY
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:
318-868-4072
Provider Business Practice Location Address Fax Number:
318-868-2019
Provider Enumeration Date:
08/22/2006