Provider First Line Business Practice Location Address:
1501 KINGS HIGHWAY
Provider Second Line Business Practice Location Address:
ADMIN BUILDING RM 504
Provider Business Practice Location Address City Name:
SHREVEPORT
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71103
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-675-6036
Provider Business Practice Location Address Fax Number:
318-675-8081
Provider Enumeration Date:
09/18/2020