Provider First Line Business Practice Location Address:
1428 CRESCENT AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOCKPORT
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70374-3106
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
985-532-2545
Provider Business Practice Location Address Fax Number:
985-532-5567
Provider Enumeration Date:
10/12/2006