Provider First Line Business Practice Location Address: 
501 BARROW ST
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
HOUMA
    Provider Business Practice Location Address State Name: 
LA
    Provider Business Practice Location Address Postal Code: 
70360-4605
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
985-872-4020
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
04/29/2020