Provider First Line Business Practice Location Address:
525 RUSH STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COUSHATTA
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71019
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-932-5719
Provider Business Practice Location Address Fax Number:
866-593-7030
Provider Enumeration Date:
06/14/2010