Provider First Line Business Practice Location Address:
1213 SOUTH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VINTON
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70668-4509
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-949-5500
Provider Business Practice Location Address Fax Number:
318-949-5555
Provider Enumeration Date:
10/14/2013