Provider First Line Business Practice Location Address:
204 MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOGANSPORT
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71049-2997
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-697-4381
Provider Business Practice Location Address Fax Number:
318-697-5311
Provider Enumeration Date:
06/12/2017