Provider First Line Business Practice Location Address:
2520 BERT KOUNS LOOP
Provider Second Line Business Practice Location Address:
SUITE 215
Provider Business Practice Location Address City Name:
SHREVEPORT
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71118-3130
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-212-5970
Provider Business Practice Location Address Fax Number:
318-212-5975
Provider Enumeration Date:
08/24/2005