Provider First Line Business Practice Location Address:
412 W UNIVERSITY AVE
Provider Second Line Business Practice Location Address:
SUITE 105
Provider Business Practice Location Address City Name:
LAFAYETTE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70506-3671
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
337-261-1571
Provider Business Practice Location Address Fax Number:
337-261-1067
Provider Enumeration Date:
07/31/2006