Provider First Line Business Practice Location Address:
707 DR. MICHAEL DEBAKEY DRIVE
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:
70601-5728
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
337-433-0762
Provider Business Practice Location Address Fax Number:
337-433-4868
Provider Enumeration Date:
11/15/2005