Provider First Line Business Practice Location Address:
1666 E BERT KOUNS LOOP
Provider Second Line Business Practice Location Address:
SUITE 145
Provider Business Practice Location Address City Name:
SHREVEPORT
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71105-5714
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-797-9199
Provider Business Practice Location Address Fax Number:
318-797-9193
Provider Enumeration Date:
08/15/2005