Provider First Line Business Practice Location Address:
1106 N MARTIN LUTHER KING HWY
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:
70601-2048
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
337-436-7833
Provider Business Practice Location Address Fax Number:
337-436-1119
Provider Enumeration Date:
08/14/2010