Provider First Line Business Practice Location Address:
4212 W CONGRESS ST
Provider Second Line Business Practice Location Address:
STE. 3300C
Provider Business Practice Location Address City Name:
LAFAYETTE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70506-6771
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
337-989-1222
Provider Business Practice Location Address Fax Number:
337-989-2672
Provider Enumeration Date:
02/07/2007