Provider First Line Business Practice Location Address:
7047 HIGHWAY 190 EAST SERVICE RD
Provider Second Line Business Practice Location Address:
EAST SERVICE ROAD
Provider Business Practice Location Address City Name:
COVINGTON
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70433-4955
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
985-327-0594
Provider Business Practice Location Address Fax Number:
985-327-0597
Provider Enumeration Date:
08/13/2009