Provider First Line Business Practice Location Address:
1666 E BERT KOUNS INDUSTRIAL LOOP STE 105
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SHREVEPORT
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71105-5718
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-212-3520
Provider Business Practice Location Address Fax Number:
318-212-3525
Provider Enumeration Date:
11/15/2007