Provider First Line Business Practice Location Address: 
611 W 2ND ST
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
HOMER
    Provider Business Practice Location Address State Name: 
LA
    Provider Business Practice Location Address Postal Code: 
71040-3221
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
318-265-4542
    Provider Business Practice Location Address Fax Number: 
318-550-4271
    Provider Enumeration Date: 
07/18/2014