Provider First Line Business Practice Location Address: 
1232 CAMELLIA BLVD STE B
    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: 
70508-6973
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
337-235-5437
    Provider Business Practice Location Address Fax Number: 
337-443-0989
    Provider Enumeration Date: 
02/23/2015