Provider First Line Business Practice Location Address:
6400 PERKINS RD
Provider Second Line Business Practice Location Address:
PENNINGTON CENTER
Provider Business Practice Location Address City Name:
BATON ROUGE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70808-4124
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
225-763-2578
Provider Business Practice Location Address Fax Number:
225-763-3022
Provider Enumeration Date:
11/15/2009