Provider First Line Business Practice Location Address:
14159 HIGHWAY 16
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
AMITE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70422-4603
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
985-747-3422
Provider Business Practice Location Address Fax Number:
985-747-3424
Provider Enumeration Date:
05/24/2006