Provider First Line Business Practice Location Address:
3804 BRADY ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BATON ROUGE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70805-5903
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
225-335-6976
Provider Business Practice Location Address Fax Number:
225-343-9141
Provider Enumeration Date:
05/22/2014