Provider First Line Business Practice Location Address:
211 EAST OAK ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
AMITE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70422
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
985-748-8434
Provider Business Practice Location Address Fax Number:
985-748-9934
Provider Enumeration Date:
08/20/2006