Provider First Line Business Practice Location Address:
719 E AIRPORT AVE
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
BATON ROUGE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70806-6558
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
225-810-4785
Provider Business Practice Location Address Fax Number:
225-810-4788
Provider Enumeration Date:
06/27/2006