Provider First Line Business Practice Location Address: 
9373 BARINGER FOREMAN RD BLDG 2
    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: 
70817-6200
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
225-754-8888
    Provider Business Practice Location Address Fax Number: 
225-755-2147
    Provider Enumeration Date: 
07/19/2016