Provider First Line Business Practice Location Address:
1711 OPELOUSAS ST
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:
70601-2560
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
337-485-2188
Provider Business Practice Location Address Fax Number:
337-990-8989
Provider Enumeration Date:
03/14/2026