Provider First Line Business Practice Location Address:
15126 HWY 21 SOUTH
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BOGALUSA
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70427
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
985-732-3549
Provider Business Practice Location Address Fax Number:
985-732-3543
Provider Enumeration Date:
02/07/2007