Provider First Line Business Practice Location Address:
9050 AIRLINE 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:
70815-4103
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
225-929-7210
Provider Business Practice Location Address Fax Number:
225-930-7530
Provider Enumeration Date:
10/13/2006