Provider First Line Business Practice Location Address:
1220 MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BATON ROUGE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70802-4657
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
225-344-6345
Provider Business Practice Location Address Fax Number:
225-344-0119
Provider Enumeration Date:
06/28/2010