Provider First Line Business Practice Location Address: 
5819 E KINGS HWY
    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: 
71105-4303
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
318-861-7896
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
01/09/2021