Provider First Line Business Practice Location Address: 
3217 NEW HIGHWAY 51
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
LA PLACE
    Provider Business Practice Location Address State Name: 
LA
    Provider Business Practice Location Address Postal Code: 
70068-6436
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
985-359-1777
    Provider Business Practice Location Address Fax Number: 
985-359-1779
    Provider Enumeration Date: 
12/17/2012