Provider First Line Business Practice Location Address: 
1603 RINGGOLD AVE
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
COUSHATTA
    Provider Business Practice Location Address State Name: 
LA
    Provider Business Practice Location Address Postal Code: 
71019-9084
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
318-932-5771
    Provider Business Practice Location Address Fax Number: 
318-932-4022
    Provider Enumeration Date: 
10/09/2014