Provider First Line Business Practice Location Address:
6875 CALUMET ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BATON ROUGE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70805-6215
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
225-357-3066
Provider Business Practice Location Address Fax Number:
225-356-4156
Provider Enumeration Date:
03/19/2009