Provider First Line Business Practice Location Address:
2533 BERT KOUNS LOOP
Provider Second Line Business Practice Location Address:
SUITE 106
Provider Business Practice Location Address City Name:
SHREVEPORT
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71118-3158
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-212-5976
Provider Business Practice Location Address Fax Number:
318-212-5986
Provider Enumeration Date:
04/21/2006