Provider First Line Business Practice Location Address:
12643 JEFFERSON HWY
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:
70816-6298
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
225-751-3133
Provider Business Practice Location Address Fax Number:
225-751-3135
Provider Enumeration Date:
03/23/2007