Provider First Line Business Practice Location Address:
1453 E BERT KOUN LOOP STE 112
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:
71105-6810
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-798-9400
Provider Business Practice Location Address Fax Number:
318-795-4656
Provider Enumeration Date:
10/25/2005