Provider First Line Business Practice Location Address:
1615 JOHNSON ST
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
JENNINGS
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70546-3650
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
337-246-3556
Provider Business Practice Location Address Fax Number:
337-246-3559
Provider Enumeration Date:
08/11/2006