Provider First Line Business Practice Location Address:
555 DR. MICHAEL DEBAKEY DR.
Provider Second Line Business Practice Location Address:
SUITE 101
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:
337-439-0762
Provider Business Practice Location Address Fax Number:
337-436-8862
Provider Enumeration Date:
03/04/2008