Provider First Line Business Practice Location Address: 
9900 SMITHERMAN DR
    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: 
71115-2923
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
318-797-2240
    Provider Business Practice Location Address Fax Number: 
318-364-5193
    Provider Enumeration Date: 
08/27/2021