Provider First Line Business Practice Location Address:
421 MAIN STREET
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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-649-6111
Provider Business Practice Location Address Fax Number:
318-649-5094
Provider Enumeration Date:
08/29/2006