Provider First Line Business Practice Location Address:
12880 PLANK RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BAKER
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70714-4909
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
225-775-3994
Provider Business Practice Location Address Fax Number:
225-775-2190
Provider Enumeration Date:
09/16/2009