Provider First Line Business Practice Location Address:
353 N 12TH ST
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:
70802-4612
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
225-242-4862
Provider Business Practice Location Address Fax Number:
225-342-5193
Provider Enumeration Date:
06/15/2012