Provider First Line Business Practice Location Address:
2312 E MAIN ST
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
NEW IBERIA
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70560-4064
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
337-560-1711
Provider Business Practice Location Address Fax Number:
337-359-9102
Provider Enumeration Date:
10/25/2006