Provider First Line Business Practice Location Address:
17544 TUNICA TRACE
Provider Second Line Business Practice Location Address:
LOUISIANA STATE PENITENTIARY
Provider Business Practice Location Address City Name:
ANGOLA
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70712-1200
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
225-655-2313
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/29/2013