Provider First Line Business Practice Location Address: 
420 AVENUE F
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
BOGALUSA
    Provider Business Practice Location Address State Name: 
LA
    Provider Business Practice Location Address Postal Code: 
70427-3634
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
985-730-7001
    Provider Business Practice Location Address Fax Number: 
985-730-7006
    Provider Enumeration Date: 
08/10/2007