Provider First Line Business Practice Location Address:
11732 MARKET PLACE AVE
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
BATON ROUGE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70816-6011
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
225-291-1498
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/10/2012