Provider First Line Business Practice Location Address:
10466 AIRLINE HWY STE C
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BATON ROUGE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70816-4047
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
225-292-1969
Provider Business Practice Location Address Fax Number:
225-292-1960
Provider Enumeration Date:
01/19/2011