Provider First Line Business Practice Location Address:
5001 HIGHWAY 190 EAST SERVICE RD STE C1
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COVINGTON
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70433-4949
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
985-626-8700
Provider Business Practice Location Address Fax Number:
985-892-2055
Provider Enumeration Date:
01/18/2007