Provider First Line Business Practice Location Address: 
516 E AIRLINE HWY STE A
    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: 
70068-5004
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
985-224-2199
    Provider Business Practice Location Address Fax Number: 
985-224-2668
    Provider Enumeration Date: 
12/01/2014