Provider First Line Business Practice Location Address:
1608 S 5TH ST
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
LEESVILLE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71446-5304
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
337-392-5910
Provider Business Practice Location Address Fax Number:
337-392-1099
Provider Enumeration Date:
02/28/2008