Provider First Line Business Practice Location Address:
1709 W PRIEN LAKE RD
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
LAKE CHARLES
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70601-8360
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
337-474-5201
Provider Business Practice Location Address Fax Number:
337-474-5524
Provider Enumeration Date:
02/09/2006