Provider First Line Business Practice Location Address: 
1310 N 19TH ST STE B
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
MONROE
    Provider Business Practice Location Address State Name: 
LA
    Provider Business Practice Location Address Postal Code: 
71201-5044
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
318-966-2220
    Provider Business Practice Location Address Fax Number: 
318-966-2221
    Provider Enumeration Date: 
06/13/2017