Provider First Line Business Practice Location Address:
1736 W. PRIEN LAKE ROAD
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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
337-478-5085
Provider Business Practice Location Address Fax Number:
337-478-5086
Provider Enumeration Date:
05/31/2005