Provider First Line Business Practice Location Address:
255 BERT KOUNS LOOP
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:
71106-8150
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-682-4590
Provider Business Practice Location Address Fax Number:
318-682-4598
Provider Enumeration Date:
05/16/2006