Provider First Line Business Practice Location Address:
1455 E BERT KOUNS LOOP
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SHREVEPORT
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71105-5634
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-798-4515
Provider Business Practice Location Address Fax Number:
318-798-4530
Provider Enumeration Date:
08/31/2005