Provider First Line Business Practice Location Address:
4405 HIGHWAY 190 EAST SERVICE RD
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:
70433-4957
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
985-893-8505
Provider Business Practice Location Address Fax Number:
985-893-0093
Provider Enumeration Date:
11/30/2006