Provider First Line Business Practice Location Address:
2900 HIGHWAY 80
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HAUGHTON
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71037-7405
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-949-1771
Provider Business Practice Location Address Fax Number:
318-949-1774
Provider Enumeration Date:
02/28/2007