Provider First Line Business Practice Location Address:
2100 JEFFERSON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAFAYETTE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70501-8556
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
337-706-3428
Provider Business Practice Location Address Fax Number:
337-706-3460
Provider Enumeration Date:
09/15/2006