Provider First Line Business Practice Location Address:
622 RUSH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COUSHATTA
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71019-9255
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-932-4442
Provider Business Practice Location Address Fax Number:
318-932-4404
Provider Enumeration Date:
08/23/2005