Provider First Line Business Practice Location Address:
722 JOHNSON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TALLULAH
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71282-4533
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-574-2229
Provider Business Practice Location Address Fax Number:
318-574-2219
Provider Enumeration Date:
02/20/2008