Provider First Line Business Practice Location Address:
4615 HIGHWAY 80
Provider Second Line Business Practice Location Address:
SUITE #7
Provider Business Practice Location Address City Name:
HAUGHTON
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71037-7441
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-949-6085
Provider Business Practice Location Address Fax Number:
318-949-6084
Provider Enumeration Date:
07/21/2010