Provider First Line Business Practice Location Address: 
811 CYPRESS ST
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
WEST MONROE
    Provider Business Practice Location Address State Name: 
LA
    Provider Business Practice Location Address Postal Code: 
71291-2923
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
318-410-9919
    Provider Business Practice Location Address Fax Number: 
318-410-9989
    Provider Enumeration Date: 
02/08/2007