Provider First Line Business Practice Location Address: 
1100 N VICTOR II BLVD
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
MORGAN CITY
    Provider Business Practice Location Address State Name: 
LA
    Provider Business Practice Location Address Postal Code: 
70380-1331
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
985-385-4327
    Provider Business Practice Location Address Fax Number: 
985-385-1988
    Provider Enumeration Date: 
10/27/2011