Provider First Line Business Practice Location Address:
10154 JEFFERSON HWY
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:
70809-2725
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
225-927-5663
Provider Business Practice Location Address Fax Number:
225-928-7341
Provider Enumeration Date:
10/20/2005