Provider First Line Business Practice Location Address: 
70380 HIGHWAY 21 STE 2266
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
COVINGTON
    Provider Business Practice Location Address State Name: 
LA
    Provider Business Practice Location Address Postal Code: 
70433-8128
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
985-260-2266
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
03/30/2016