Provider First Line Business Practice Location Address: 
110 RUE PROMENADE
    Provider Second Line Business Practice Location Address: 
SUITE 101
    Provider Business Practice Location Address City Name: 
LAFAYETTE
    Provider Business Practice Location Address State Name: 
LA
    Provider Business Practice Location Address Postal Code: 
70508
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
337-289-9100
    Provider Business Practice Location Address Fax Number: 
337-289-9040
    Provider Enumeration Date: 
07/18/2014