Provider First Line Business Practice Location Address: 
160 MCVICKER ST
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
MARION
    Provider Business Practice Location Address State Name: 
LA
    Provider Business Practice Location Address Postal Code: 
71260-5408
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
318-292-4142
    Provider Business Practice Location Address Fax Number: 
318-292-4161
    Provider Enumeration Date: 
08/10/2007