Provider First Line Business Practice Location Address:
137 DR. CHILDRESS DR.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MARKSVILLE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71351
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-256-3332
Provider Business Practice Location Address Fax Number:
318-409-4040
Provider Enumeration Date:
06/01/2005