Provider First Line Business Practice Location Address:
5001 HIGHWAY 190 EAST SERVICE RD
Provider Second Line Business Practice Location Address:
SUITE D-4
Provider Business Practice Location Address City Name:
COVINGTON
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70433-4930
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
504-289-8047
Provider Business Practice Location Address Fax Number:
985-796-3181
Provider Enumeration Date:
01/16/2012