Provider First Line Business Practice Location Address:
2753 YORKTOWN DR.
Provider Second Line Business Practice Location Address:
BOX 80072
Provider Business Practice Location Address City Name:
BATON ROUGE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70898-0072
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
225-288-5793
Provider Business Practice Location Address Fax Number:
225-923-1906
Provider Enumeration Date:
06/23/2005