Provider First Line Business Practice Location Address:
17155 OLD JEFFERSON HIGHWAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PRAIRIEVILLE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70769-0798
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
225-673-1647
Provider Business Practice Location Address Fax Number:
225-673-1648
Provider Enumeration Date:
10/18/2006