Provider First Line Business Practice Location Address:
411 E VAUGHN AVE
Provider Second Line Business Practice Location Address:
SUITE 201
Provider Business Practice Location Address City Name:
RUSTON
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71270-5972
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-255-3223
Provider Business Practice Location Address Fax Number:
318-255-3181
Provider Enumeration Date:
08/05/2007