Provider First Line Business Practice Location Address:
2520 BERT KOUNS INDUSTRIAL LOOP
Provider Second Line Business Practice Location Address:
STE 104
Provider Business Practice Location Address City Name:
SHREVEPORT
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71118
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-686-0572
Provider Business Practice Location Address Fax Number:
318-697-9311
Provider Enumeration Date:
09/07/2006