Provider First Line Business Practice Location Address:
146 HWY 40
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
INDEPENDENCE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70443
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
985-878-2273
Provider Business Practice Location Address Fax Number:
985-878-9534
Provider Enumeration Date:
10/10/2008