Provider First Line Business Practice Location Address:
4200 E TEXAS ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BOSSIER CITY
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71111-2928
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-636-9991
Provider Business Practice Location Address Fax Number:
318-636-9098
Provider Enumeration Date:
06/19/2006