Provider First Line Business Practice Location Address:
11832 NEWCASTLE AVE STE 11
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:
70816-8987
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
225-291-1164
Provider Business Practice Location Address Fax Number:
225-291-1165
Provider Enumeration Date:
07/18/2007