Provider First Line Business Practice Location Address:
1006 S HARRISON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COVINGTON
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70433-3661
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
985-871-4140
Provider Business Practice Location Address Fax Number:
985-898-4150
Provider Enumeration Date:
10/17/2007