Provider First Line Business Practice Location Address:
1125 HIGHWAY 80
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HAUGHTON
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71037-9430
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-949-8476
Provider Business Practice Location Address Fax Number:
318-949-4325
Provider Enumeration Date:
05/15/2012