Provider First Line Business Practice Location Address:
728 NORTH BOULEVARD
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:
70802-5724
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
225-293-6774
Provider Business Practice Location Address Fax Number:
225-291-9229
Provider Enumeration Date:
11/04/2005