Provider First Line Business Practice Location Address: 
83370 HIGHWAY 25
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
FOLSOM
    Provider Business Practice Location Address State Name: 
LA
    Provider Business Practice Location Address Postal Code: 
70437
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
985-796-3364
    Provider Business Practice Location Address Fax Number: 
985-796-9116
    Provider Enumeration Date: 
12/08/2006