Provider First Line Business Practice Location Address:
4465 HIGHWAY 190 EAST SERVICE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COVINGTON
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70433-4957
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
504-460-0289
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/28/2008