Provider First Line Business Practice Location Address:
5001 HIGHWAY 190 EAST SERVICE RD
Provider Second Line Business Practice Location Address:
SUITE B1
Provider Business Practice Location Address City Name:
COVINGTON
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70433-4930
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
985-867-3435
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/31/2006