Provider First Line Business Practice Location Address:
71207 HIGHWAY 21 STE B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COVINGTON
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70433-7121
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
985-867-5310
Provider Business Practice Location Address Fax Number:
985-867-5243
Provider Enumeration Date:
11/17/2006