Provider First Line Business Practice Location Address:
6516 EAST MYRTLE STREET
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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
225-774-7320
Provider Business Practice Location Address Fax Number:
225-774-5432
Provider Enumeration Date:
10/18/2006