Provider First Line Business Practice Location Address: 
110 LOUISIANA AVE
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
FERRIDAY
    Provider Business Practice Location Address State Name: 
LA
    Provider Business Practice Location Address Postal Code: 
71334
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
318-757-3270
    Provider Business Practice Location Address Fax Number: 
318-757-3278
    Provider Enumeration Date: 
03/15/2018