Provider First Line Business Practice Location Address:
1666 E BERT KOUNS LOOP
Provider Second Line Business Practice Location Address:
SUITE 105
Provider Business Practice Location Address City Name:
SHREVEPORT
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71105-5714
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-212-3520
Provider Business Practice Location Address Fax Number:
318-212-3525
Provider Enumeration Date:
06/22/2006