Provider First Line Business Practice Location Address:
4707 DENHAM ST RM C205
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:
70805-1622
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
225-655-6422
Provider Business Practice Location Address Fax Number:
225-341-5903
Provider Enumeration Date:
02/27/2024