Provider First Line Business Practice Location Address:
1204 W 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:
70601-8371
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
337-526-6774
Provider Business Practice Location Address Fax Number:
337-562-8356
Provider Enumeration Date:
06/14/2005