Provider First Line Business Practice Location Address:
3110 BERT KOUNS INDUSTRIAL LOOP STE G
Provider Second Line Business Practice Location Address:
BOX 11
Provider Business Practice Location Address City Name:
SHREVEPORT
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71118
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-686-1186
Provider Business Practice Location Address Fax Number:
318-686-1053
Provider Enumeration Date:
07/31/2012