Provider First Line Business Practice Location Address:
69154 HWY 190 SERV RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COVINGTON
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70433-5140
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
985-893-2845
Provider Business Practice Location Address Fax Number:
985-893-2654
Provider Enumeration Date:
05/25/2006