Provider First Line Business Practice Location Address:
707A E PRIEN LAKE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAKE CHARLES
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70601-8613
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
337-475-3200
Provider Business Practice Location Address Fax Number:
337-475-3222
Provider Enumeration Date:
12/01/2005