Provider First Line Business Practice Location Address:
115 CHERRY ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAKE PROVIDENCE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71254-6303
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-559-1166
Provider Business Practice Location Address Fax Number:
318-559-2939
Provider Enumeration Date:
04/11/2007