Provider First Line Business Practice Location Address:
1400 E BERT KOUNS INDUSTRIAL LOOP
Provider Second Line Business Practice Location Address:
SUITE 105
Provider Business Practice Location Address City Name:
SHREVEPORT
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71105-5603
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-238-6001
Provider Business Practice Location Address Fax Number:
318-238-6002
Provider Enumeration Date:
09/21/2010