Provider First Line Business Practice Location Address:
604 KIMBROUGH AVE
Provider Second Line Business Practice Location Address:
BLDG Q
Provider Business Practice Location Address City Name:
TALLULAH
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71282
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-574-0098
Provider Business Practice Location Address Fax Number:
318-574-0066
Provider Enumeration Date:
12/05/2011