Provider First Line Business Practice Location Address:
12147 COURSEY BLVD
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
BATON ROUGE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70816-4410
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
225-771-8849
Provider Business Practice Location Address Fax Number:
225-771-8876
Provider Enumeration Date:
02/15/2016