Provider First Line Business Practice Location Address:
209 SYCAMORE STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOGANSPORT
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71049
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-697-4523
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/26/2007