Provider First Line Business Practice Location Address:
10235 JEFFERSON HWY STE C
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:
70809-2728
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
225-376-6157
Provider Business Practice Location Address Fax Number:
225-332-0662
Provider Enumeration Date:
05/27/2006