Provider First Line Business Practice Location Address:
1541 IRVING PLACE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SHREVEPORT
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71101
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-424-4623
Provider Business Practice Location Address Fax Number:
318-424-4678
Provider Enumeration Date:
10/19/2006