Provider First Line Business Practice Location Address:
2400 HOSPITAL DR
Provider Second Line Business Practice Location Address:
STE 120
Provider Business Practice Location Address City Name:
BOSSIER CITY
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71111-2386
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-742-6710
Provider Business Practice Location Address Fax Number:
318-747-5393
Provider Enumeration Date:
06/27/2005