Provider First Line Business Practice Location Address:
14635 S HARRELLS FERRY RD
Provider Second Line Business Practice Location Address:
STE. 3-A
Provider Business Practice Location Address City Name:
BATON ROUGE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70816-2959
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
225-751-5412
Provider Business Practice Location Address Fax Number:
225-751-5847
Provider Enumeration Date:
12/28/2012