Provider First Line Business Practice Location Address: 
515 EAST 6TH STREET
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
CROWLEY
    Provider Business Practice Location Address State Name: 
LA
    Provider Business Practice Location Address Postal Code: 
70526
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
337-783-3075
    Provider Business Practice Location Address Fax Number: 
337-783-2548
    Provider Enumeration Date: 
01/10/2008