Provider First Line Business Practice Location Address:
815 SOUTH 10TH STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LEESVILLE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71446
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
504-274-1102
Provider Business Practice Location Address Fax Number:
504-832-2116
Provider Enumeration Date:
07/27/2007