Provider First Line Business Practice Location Address:
17534 OLD JEFFERSON HWY
Provider Second Line Business Practice Location Address:
SUITE A-1
Provider Business Practice Location Address City Name:
PRAIRIEVILLE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70769-3929
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
225-673-4370
Provider Business Practice Location Address Fax Number:
225-673-2241
Provider Enumeration Date:
10/19/2006