Provider First Line Business Practice Location Address: 
124 TANGLEWOOD DR
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
BUNKIE
    Provider Business Practice Location Address State Name: 
LA
    Provider Business Practice Location Address Postal Code: 
71322-1948
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
318-481-0060
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
12/03/2015