Provider First Line Business Practice Location Address: 
511 ULSTER ST
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
BOYCE
    Provider Business Practice Location Address State Name: 
LA
    Provider Business Practice Location Address Postal Code: 
71409
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
318-793-2400
    Provider Business Practice Location Address Fax Number: 
318-793-9100
    Provider Enumeration Date: 
02/26/2007