Provider First Line Business Practice Location Address:
2301 E 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:
70601-7976
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
337-478-6172
Provider Business Practice Location Address Fax Number:
337-474-4935
Provider Enumeration Date:
01/06/2010