Provider First Line Business Practice Location Address:
524 DR MICHAEL DEBAKEY DR
Provider Second Line Business Practice Location Address:
BUILDING 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:
70601-5725
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
337-480-8990
Provider Business Practice Location Address Fax Number:
337-439-1133
Provider Enumeration Date:
12/29/2006