Provider First Line Business Practice Location Address:
8211 SUMMA AVE SUITE B
Provider Second Line Business Practice Location Address:
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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
888-977-7632
Provider Business Practice Location Address Fax Number:
800-410-8002
Provider Enumeration Date:
01/17/2023