Provider First Line Business Practice Location Address:
8202 KELWOOD AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BATON ROUGE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70806-4801
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
225-928-0798
Provider Business Practice Location Address Fax Number:
225-927-8115
Provider Enumeration Date:
10/12/2006