Provider First Line Business Practice Location Address:
1318 FLORIDA BLVD
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
DENHAM SPRINGS
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70726-4600
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
225-243-5573
Provider Business Practice Location Address Fax Number:
225-243-6029
Provider Enumeration Date:
01/27/2008