Provider First Line Business Practice Location Address:
400 MEMPHIS ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BOGALUSA
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70427-3862
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
985-730-7177
Provider Business Practice Location Address Fax Number:
985-730-6898
Provider Enumeration Date:
04/29/2011