Provider First Line Business Practice Location Address:
636 LOBDELL AVE
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:
70806-6318
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
504-919-7511
Provider Business Practice Location Address Fax Number:
504-656-2865
Provider Enumeration Date:
05/31/2012