Provider First Line Business Practice Location Address:
52579 HIGHWAY 51 S
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
INDEPENDENCE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70443-2231
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
985-878-9421
Provider Business Practice Location Address Fax Number:
985-878-1306
Provider Enumeration Date:
05/04/2006