Provider First Line Business Practice Location Address: 
7600 FERN AVE STE 400
    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: 
71105-5672
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
318-741-9898
    Provider Business Practice Location Address Fax Number: 
318-741-6986
    Provider Enumeration Date: 
10/30/2014