Provider First Line Business Practice Location Address:
11607 SOUTHFORK AVE BLDG B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BATON ROUGE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70816-5220
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
877-418-2978
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/09/2026