Provider First Line Business Practice Location Address: 
429 W AIRLINE HWY
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
LA PLACE
    Provider Business Practice Location Address State Name: 
LA
    Provider Business Practice Location Address Postal Code: 
70068-3817
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
985-618-3403
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
08/24/2022