Provider First Line Business Practice Location Address:
2004 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:
70601-7874
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
337-474-7170
Provider Business Practice Location Address Fax Number:
337-474-7171
Provider Enumeration Date:
02/27/2007