Provider First Line Business Practice Location Address:
1736 W 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:
70601-8361
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
337-491-7730
Provider Business Practice Location Address Fax Number:
337-478-5086
Provider Enumeration Date:
06/29/2006