Provider First Line Business Practice Location Address:
800 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:
70601-8379
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
337-502-4550
Provider Business Practice Location Address Fax Number:
337-502-4555
Provider Enumeration Date:
03/30/2010