Provider First Line Business Practice Location Address:
1532 IRVING PL
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SHREVEPORT
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71101-4604
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-865-7111
Provider Business Practice Location Address Fax Number:
318-865-7771
Provider Enumeration Date:
01/03/2007