Provider First Line Business Practice Location Address: 
2802 RYAN ST
    Provider Second Line Business Practice Location Address: 
SUITE 26
    Provider Business Practice Location Address City Name: 
LAKE CHARLES
    Provider Business Practice Location Address State Name: 
LA
    Provider Business Practice Location Address Postal Code: 
70601-7393
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
318-219-5159
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
09/29/2009