Provider First Line Business Practice Location Address: 
510 W UNIVERSITY AVE
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
LAFAYETTE
    Provider Business Practice Location Address State Name: 
LA
    Provider Business Practice Location Address Postal Code: 
70506-3652
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
337-781-1667
    Provider Business Practice Location Address Fax Number: 
337-284-0984
    Provider Enumeration Date: 
06/13/2017