Provider First Line Business Practice Location Address:
1405 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:
70601-8391
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
337-245-1537
Provider Business Practice Location Address Fax Number:
337-570-1213
Provider Enumeration Date:
10/07/2008