Provider First Line Business Practice Location Address:
1500 LINE AVENUE
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
SHREVEPORT
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71101
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-635-3052
Provider Business Practice Location Address Fax Number:
318-632-6087
Provider Enumeration Date:
08/19/2005