Provider First Line Business Practice Location Address:
825 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:
70601-8378
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
337-508-2286
Provider Business Practice Location Address Fax Number:
227-508-2270
Provider Enumeration Date:
04/29/2008