Provider First Line Business Practice Location Address:
606 E 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:
70601-8612
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
337-474-2493
Provider Business Practice Location Address Fax Number:
337-474-2591
Provider Enumeration Date:
06/27/2008