Provider First Line Business Practice Location Address:
628 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:
70601-8686
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
337-235-2149
Provider Business Practice Location Address Fax Number:
337-231-4012
Provider Enumeration Date:
10/03/2005