Provider First Line Business Practice Location Address:
124 S 13TH ST BLDG 2
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OAKDALE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71463-2935
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-215-1413
Provider Business Practice Location Address Fax Number:
318-215-1415
Provider Enumeration Date:
03/17/2006