Provider First Line Business Practice Location Address:
12090 S HARRELLS FERRY RD STE R
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:
70816-2470
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
225-256-1429
Provider Business Practice Location Address Fax Number:
225-256-1510
Provider Enumeration Date:
06/30/2020