Provider First Line Business Practice Location Address:
501 E UNIVERSITY AVE
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:
70503-2118
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
337-256-1868
Provider Business Practice Location Address Fax Number:
337-704-2130
Provider Enumeration Date:
11/26/2007