Provider First Line Business Practice Location Address:
5001 HWY 190, SUITE B-1
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COVINGTON
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70433
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
985-264-2127
Provider Business Practice Location Address Fax Number:
985-867-3438
Provider Enumeration Date:
02/26/2007