Provider First Line Business Practice Location Address:
5159 HIGHWAY 4 E
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COLUMBIA
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71418-3580
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-649-3625
Provider Business Practice Location Address Fax Number:
318-649-5731
Provider Enumeration Date:
01/19/2012