Provider First Line Business Practice Location Address:
114 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:
70601-8571
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
337-310-0632
Provider Business Practice Location Address Fax Number:
337-436-2153
Provider Enumeration Date:
03/16/2021