Provider First Line Business Practice Location Address:
2002 E KENTUCKY AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RUSTON
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71270-6623
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-255-5131
Provider Business Practice Location Address Fax Number:
318-255-5769
Provider Enumeration Date:
06/02/2005