Provider First Line Business Practice Location Address:
5401 SHED ROAD
Provider Second Line Business Practice Location Address:
NORTHWEST SUPPORTS & SERVICES CENTER
Provider Business Practice Location Address City Name:
BOSSIER CITY
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71111
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-741-5242
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/26/2011