Provider First Line Business Practice Location Address: 
102 QUEBEC ST
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
HOUMA
    Provider Business Practice Location Address State Name: 
LA
    Provider Business Practice Location Address Postal Code: 
70364-3842
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
985-232-7880
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
08/30/2011