Provider First Line Business Practice Location Address:
1209 ROYAL AVENUE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MONROE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71201
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-812-0119
Provider Business Practice Location Address Fax Number:
318-812-0136
Provider Enumeration Date:
12/11/2006