Provider First Line Business Practice Location Address:
1 NORTH STADIUM DRIVE BROUSSARD CENTER FOR ATHLETIC TR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BATON ROUGE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70803-0001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
715-559-9579
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/29/2023