Provider First Line Business Practice Location Address: 
3728 FREDERICK ST
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
SHREVEPORT
    Provider Business Practice Location Address State Name: 
LA
    Provider Business Practice Location Address Postal Code: 
71109-3202
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
318-367-2191
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
11/01/2022