Provider First Line Business Practice Location Address:
281 WEST 4TH ST.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
INDEPENDENCE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70443-2386
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
985-878-0066
Provider Business Practice Location Address Fax Number:
985-878-0626
Provider Enumeration Date:
07/19/2005