Provider First Line Business Practice Location Address:
1209 LEESVILLE AVE
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:
70802-4336
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
225-219-5200
Provider Business Practice Location Address Fax Number:
225-219-4903
Provider Enumeration Date:
07/22/2006