Provider First Line Business Practice Location Address:
5916 FAIRFIELD AVE
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
SHREVEPORT
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71106-1914
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-861-1346
Provider Business Practice Location Address Fax Number:
318-861-1346
Provider Enumeration Date:
07/03/2005