Provider First Line Business Practice Location Address:
1585 3RD ST DEPT OF
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT POLK
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71459-5102
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
337-531-6090
Provider Business Practice Location Address Fax Number:
337-531-3760
Provider Enumeration Date:
03/12/2007