Provider First Line Business Practice Location Address:
640 AVENUE V
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BOGALUSA
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70427
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
985-735-5216
Provider Business Practice Location Address Fax Number:
985-735-1923
Provider Enumeration Date:
11/29/2007