Provider First Line Business Practice Location Address:
5001 HIGHWAY 190 EAST SERVICE RD
Provider Second Line Business Practice Location Address:
SUITE D
Provider Business Practice Location Address City Name:
COVINGTON
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70433-4930
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
985-893-6860
Provider Business Practice Location Address Fax Number:
985-893-6919
Provider Enumeration Date:
04/04/2007