Provider First Line Business Practice Location Address:
2600 JOHNSTON ST
Provider Second Line Business Practice Location Address:
SUITE 110
Provider Business Practice Location Address City Name:
LAFAYETTE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70503-3269
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
337-266-5155
Provider Business Practice Location Address Fax Number:
866-680-6420
Provider Enumeration Date:
10/10/2008