Provider First Line Business Practice Location Address:
7600 GENERAL MOTORS BLVD
Provider Second Line Business Practice Location Address:
MEDICAL DEPARTMENT
Provider Business Practice Location Address City Name:
SHREVEPORT
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71129-9426
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-683-9503
Provider Business Practice Location Address Fax Number:
318-683-9697
Provider Enumeration Date:
01/19/2007