Provider First Line Business Practice Location Address:
200 AVENUE C
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:
70615-6816
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
337-436-6664
Provider Business Practice Location Address Fax Number:
337-436-0250
Provider Enumeration Date:
05/10/2007