Provider First Line Business Practice Location Address: 
29 HIGHWAY 454
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
PINEVILLE
    Provider Business Practice Location Address State Name: 
LA
    Provider Business Practice Location Address Postal Code: 
71360
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
318-792-8448
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
12/31/2013