Provider First Line Business Practice Location Address:
540 DURHAM ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BASTROP
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71220-5013
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-283-2200
Provider Business Practice Location Address Fax Number:
318-283-1200
Provider Enumeration Date:
09/25/2006