Provider First Line Business Practice Location Address:
5976 HIGHWAY 65 N
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAKE PROVIDENCE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71254-5235
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-559-4050
Provider Business Practice Location Address Fax Number:
318-559-4052
Provider Enumeration Date:
10/25/2005