Provider First Line Business Practice Location Address:
3600 FLORIDA BLVD
Provider Second Line Business Practice Location Address:
ROOM 4613
Provider Business Practice Location Address City Name:
BATON ROUGE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70806-3842
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
225-387-7724
Provider Business Practice Location Address Fax Number:
225-381-6922
Provider Enumeration Date:
12/22/2005