Provider First Line Business Practice Location Address:
204 TENSAS AVE
Provider Second Line Business Practice Location Address:
PO BOX 529
Provider Business Practice Location Address City Name:
WATERPROOF
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71375
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
562-291-0559
Provider Business Practice Location Address Fax Number:
310-861-9090
Provider Enumeration Date:
01/30/2026