Provider First Line Business Practice Location Address:
8312 JEFFERSON HWY
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:
70809-8657
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
225-752-2760
Provider Business Practice Location Address Fax Number:
225-751-6908
Provider Enumeration Date:
03/17/2014