Provider First Line Business Practice Location Address:
3975 INTERSTATE 49 S SERVICE RD
Provider Second Line Business Practice Location Address:
STE 201
Provider Business Practice Location Address City Name:
OPELOUSAS
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70570-0775
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
337-407-2795
Provider Business Practice Location Address Fax Number:
337-407-2798
Provider Enumeration Date:
02/20/2007