Provider First Line Business Practice Location Address:
7223 MISSISSIPPI AVE, BLDG #1561
Provider Second Line Business Practice Location Address:
ATTN: CREDENTIALS COORDINATOR
Provider Business Practice Location Address City Name:
FORT POLK
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71459-5110
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
337-531-2327
Provider Business Practice Location Address Fax Number:
337-531-6356
Provider Enumeration Date:
08/29/2007