Provider First Line Business Practice Location Address:
11822 JUSTICE AVE
Provider Second Line Business Practice Location Address:
SUITE A6
Provider Business Practice Location Address City Name:
BATON ROUGE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70816-2306
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
225-296-1346
Provider Business Practice Location Address Fax Number:
225-296-1347
Provider Enumeration Date:
12/11/2007