Provider First Line Business Practice Location Address:
10270 HIGHWAY 16
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
AMITE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70422-4170
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
985-748-5280
Provider Business Practice Location Address Fax Number:
985-748-5152
Provider Enumeration Date:
02/28/2007