Provider First Line Business Practice Location Address:
1001 3RD AVENUE
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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
337-433-1429
Provider Business Practice Location Address Fax Number:
337-433-9971
Provider Enumeration Date:
09/20/2006