Provider First Line Business Practice Location Address:
2924 KNIGHT ST, BLDG 3
Provider Second Line Business Practice Location Address:
SUITE 357
Provider Business Practice Location Address City Name:
SHREVEPORT
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71105
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-861-0194
Provider Business Practice Location Address Fax Number:
318-861-0284
Provider Enumeration Date:
01/22/2007