Provider First Line Business Practice Location Address:
3804 JOHNSTON ST
Provider Second Line Business Practice Location Address:
BUILDING 1
Provider Business Practice Location Address City Name:
LAFAYETTE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70503-3851
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
337-984-3104
Provider Business Practice Location Address Fax Number:
337-984-4446
Provider Enumeration Date:
02/29/2012