Provider First Line Business Practice Location Address:
403 2ND 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:
71254-2605
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-559-2012
Provider Business Practice Location Address Fax Number:
318-559-3553
Provider Enumeration Date:
06/15/2012