Provider First Line Business Practice Location Address:
5159 HIGHWAY 4 E
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COLUMBIA
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71418-3581
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-362-3270
Provider Business Practice Location Address Fax Number:
318-362-3268
Provider Enumeration Date:
10/18/2006