Provider First Line Business Practice Location Address:
2115 FITZENREITER RD
Provider Second Line Business Practice Location Address:
SBHC
Provider Business Practice Location Address City Name:
LAKE CHARLES
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70601-1139
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
337-217-4890
Provider Business Practice Location Address Fax Number:
337-491-7132
Provider Enumeration Date:
10/24/2013