Provider First Line Business Practice Location Address:
8704 JEFFERSON HWY
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
BATON ROUGE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70809-2233
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
225-928-8989
Provider Business Practice Location Address Fax Number:
225-928-8689
Provider Enumeration Date:
05/31/2006