Provider First Line Business Practice Location Address:
2433 EAST 70TH STREET
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
SHREVEPORT
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71105
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-797-4988
Provider Business Practice Location Address Fax Number:
318-797-4168
Provider Enumeration Date:
03/09/2007