Provider First Line Business Practice Location Address:
2250 HOSPITAL DR
Provider Second Line Business Practice Location Address:
SUITE 132
Provider Business Practice Location Address City Name:
BOSSIER CITY
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71111-2167
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-747-5812
Provider Business Practice Location Address Fax Number:
318-747-5841
Provider Enumeration Date:
05/23/2007