Provider First Line Business Practice Location Address:
14635 S HARRELLS FERRY RD
Provider Second Line Business Practice Location Address:
SUITE 6 C
Provider Business Practice Location Address City Name:
BATON ROUGE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70816-2959
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
225-755-5715
Provider Business Practice Location Address Fax Number:
225-218-4177
Provider Enumeration Date:
12/11/2006