Provider First Line Business Practice Location Address: 
520 OLIVE ST
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
SHREVEPORT
    Provider Business Practice Location Address State Name: 
LA
    Provider Business Practice Location Address Postal Code: 
71104
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
318-562-6903
    Provider Business Practice Location Address Fax Number: 
318-209-3417
    Provider Enumeration Date: 
10/05/2012