Provider First Line Business Practice Location Address: 
242 WEST SHAMROCK STREET
    Provider Second Line Business Practice Location Address: 
UNIT 2, ROOM 120
    Provider Business Practice Location Address City Name: 
PINEVILLE
    Provider Business Practice Location Address State Name: 
LA
    Provider Business Practice Location Address Postal Code: 
71360-6439
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
318-484-6665
    Provider Business Practice Location Address Fax Number: 
318-484-6483
    Provider Enumeration Date: 
09/09/2010