Provider First Line Business Practice Location Address: 
320 WILLOW ST
    Provider Second Line Business Practice Location Address: 
SUITE B
    Provider Business Practice Location Address City Name: 
FRANKLIN
    Provider Business Practice Location Address State Name: 
LA
    Provider Business Practice Location Address Postal Code: 
70538-6139
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
337-828-0505
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
07/01/2008