Provider First Line Business Practice Location Address:
10202 JEFFERSON HWY
Provider Second Line Business Practice Location Address:
BLDG D
Provider Business Practice Location Address City Name:
BATON ROUGE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70809-2727
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
225-768-8833
Provider Business Practice Location Address Fax Number:
225-769-4839
Provider Enumeration Date:
01/23/2008