Provider First Line Business Practice Location Address:
319 MEMPHIS ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BOGALUSA
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70427-3845
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
985-735-9029
Provider Business Practice Location Address Fax Number:
985-735-9489
Provider Enumeration Date:
10/17/2009