Provider First Line Business Practice Location Address:
9582 MAMMOTH AVE
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
BATON ROUGE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70814-4109
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
225-270-2925
Provider Business Practice Location Address Fax Number:
225-924-0249
Provider Enumeration Date:
07/25/2007