Provider First Line Business Practice Location Address: 
401 AUDUBON BLVD
    Provider Second Line Business Practice Location Address: 
SUITE 204B
    Provider Business Practice Location Address City Name: 
LAFAYETTE
    Provider Business Practice Location Address State Name: 
LA
    Provider Business Practice Location Address Postal Code: 
70503-2676
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
337-264-7128
    Provider Business Practice Location Address Fax Number: 
337-264-7168
    Provider Enumeration Date: 
12/16/2014