Provider First Line Business Practice Location Address:
1005 JOHNSON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TALLULAH
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71282-5215
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-574-5273
Provider Business Practice Location Address Fax Number:
318-574-2218
Provider Enumeration Date:
10/27/2006