Provider First Line Business Practice Location Address:
1202 LOUISIANA AVENUE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SHREVEPORT
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71101-3910
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-212-8780
Provider Business Practice Location Address Fax Number:
318-212-6752
Provider Enumeration Date:
06/09/2005