Provider First Line Business Practice Location Address:
2508 BERT KOUNS INDUSTRIAL LOOP
Provider Second Line Business Practice Location Address:
SUITE 201
Provider Business Practice Location Address City Name:
SHREVEPORT
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71118-3133
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-212-5790
Provider Business Practice Location Address Fax Number:
318-212-5795
Provider Enumeration Date:
04/13/2011