Provider First Line Business Practice Location Address:
650 HOLT STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BASTROP
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71220-0650
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-281-0322
Provider Business Practice Location Address Fax Number:
318-281-3770
Provider Enumeration Date:
10/03/2005