Provider First Line Business Practice Location Address: 
201 RUE DE JEAN
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
LAFAYETTE
    Provider Business Practice Location Address State Name: 
LA
    Provider Business Practice Location Address Postal Code: 
70508-3261
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
337-362-2500
    Provider Business Practice Location Address Fax Number: 
337-362-2400
    Provider Enumeration Date: 
03/20/2018