Provider First Line Business Practice Location Address: 
2001 DOCTORS DR
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
SPRINGHILL
    Provider Business Practice Location Address State Name: 
LA
    Provider Business Practice Location Address Postal Code: 
71075-4526
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
318-539-1000
    Provider Business Practice Location Address Fax Number: 
318-539-4085
    Provider Enumeration Date: 
02/13/2006