Provider First Line Business Practice Location Address:
1403 JOHNSON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TALLULAH
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71282-5513
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-574-0765
Provider Business Practice Location Address Fax Number:
318-493-5085
Provider Enumeration Date:
11/22/2006