Provider First Line Business Practice Location Address:
9919 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:
70809-2769
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
225-293-1434
Provider Business Practice Location Address Fax Number:
225-291-3254
Provider Enumeration Date:
11/07/2005