Provider First Line Business Practice Location Address:
215 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:
70601-8450
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
337-502-8706
Provider Business Practice Location Address Fax Number:
337-210-1271
Provider Enumeration Date:
06/29/2023