Provider First Line Business Practice Location Address: 
407 CINCINNATI ST
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
DELHI
    Provider Business Practice Location Address State Name: 
LA
    Provider Business Practice Location Address Postal Code: 
71232-3007
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
318-878-5171
    Provider Business Practice Location Address Fax Number: 
318-878-8638
    Provider Enumeration Date: 
03/31/2006