Provider First Line Business Practice Location Address:
90 LOUIS PRIMA DR STE A
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:
70433-5958
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-742-7187
Provider Business Practice Location Address Fax Number:
360-890-4099
Provider Enumeration Date:
02/24/2011