Provider First Line Business Practice Location Address:
9131 INTERLINE AVE
Provider Second Line Business Practice Location Address:
SUITE 2A
Provider Business Practice Location Address City Name:
BATON ROUGE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70809-1957
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
225-389-6844
Provider Business Practice Location Address Fax Number:
225-400-9674
Provider Enumeration Date:
03/19/2012