Provider First Line Business Practice Location Address:
501 MEDICAL CENTER DRIVE BOX 30140
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
ALEXANDRIA
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71301
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-443-5439
Provider Business Practice Location Address Fax Number:
318-487-9584
Provider Enumeration Date:
05/23/2005