Provider First Line Business Practice Location Address:
2530 BERT KOUNS LOOP
Provider Second Line Business Practice Location Address:
SUITE 138
Provider Business Practice Location Address City Name:
SHREVEPORT
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71118-3132
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-588-4726
Provider Business Practice Location Address Fax Number:
318-900-7828
Provider Enumeration Date:
09/01/2009