Provider First Line Business Practice Location Address: 
16242 CHANDLER PL
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
HAMMOND
    Provider Business Practice Location Address State Name: 
LA
    Provider Business Practice Location Address Postal Code: 
70401-7251
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
985-215-1218
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
09/04/2007