Provider First Line Business Practice Location Address:
640 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:
70601-8316
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-257-6800
Provider Business Practice Location Address Fax Number:
503-257-0288
Provider Enumeration Date:
07/20/2010