Provider First Line Business Practice Location Address:
7656 JEFFERSON HWY
Provider Second Line Business Practice Location Address:
SUITE 1A
Provider Business Practice Location Address City Name:
BATON ROUGE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70809-1389
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
225-928-8686
Provider Business Practice Location Address Fax Number:
225-928-8485
Provider Enumeration Date:
11/10/2010