Provider First Line Business Practice Location Address:
1201 JEFFERSON HWY
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
JEFFERSON
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70121-2439
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
504-834-2810
Provider Business Practice Location Address Fax Number:
504-828-6457
Provider Enumeration Date:
12/30/2005