Provider First Line Business Practice Location Address:
1245 S COLLEGE RD
Provider Second Line Business Practice Location Address:
BLDG 5
Provider Business Practice Location Address City Name:
LAFAYETTE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70503-2917
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
337-235-6886
Provider Business Practice Location Address Fax Number:
337-235-6892
Provider Enumeration Date:
10/17/2016