Provider First Line Business Practice Location Address: 
4150 NELSON RD STE C10
    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: 
70605-4169
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
337-474-0653
    Provider Business Practice Location Address Fax Number: 
337-474-0639
    Provider Enumeration Date: 
07/14/2008