Provider First Line Business Practice Location Address:
5225 CAPITOL HEIGHTS AVE
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
BATON ROUGE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70806-6066
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
225-439-2137
Provider Business Practice Location Address Fax Number:
225-927-4598
Provider Enumeration Date:
05/10/2010