Provider First Line Business Practice Location Address:
628 N 4TH ST
Provider Second Line Business Practice Location Address:
BIN#4
Provider Business Practice Location Address City Name:
BATON ROUGE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70802-5342
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
225-342-8064
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/13/2012