Provider First Line Business Practice Location Address:
430 W SOUTH AVENUE
Provider Second Line Business Practice Location Address:
BOX 909
Provider Business Practice Location Address City Name:
WINNFIELD
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71483-3424
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-628-6900
Provider Business Practice Location Address Fax Number:
318-628-6111
Provider Enumeration Date:
03/19/2007