Provider First Line Business Practice Location Address:
11911 JUSTICE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BATON ROUGE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70816-2373
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
225-751-5412
Provider Business Practice Location Address Fax Number:
225-751-5847
Provider Enumeration Date:
06/30/2006