Provider First Line Business Practice Location Address:
2004 CARTER ST STE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VIDALIA
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71373-3003
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-336-4196
Provider Business Practice Location Address Fax Number:
318-336-4431
Provider Enumeration Date:
08/31/2006