Provider First Line Business Practice Location Address:
910 8TH AVENUE
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:
70601-4832
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
337-488-9111
Provider Business Practice Location Address Fax Number:
337-439-1526
Provider Enumeration Date:
02/15/2012