Provider First Line Business Practice Location Address:
12511 PLANK RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BAKER
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70714-4902
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
224-774-6446
Provider Business Practice Location Address Fax Number:
224-774-6608
Provider Enumeration Date:
05/03/2007