Individual
JUSTIN CORY WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
DIVE IDC
Contact information
Practice address
699 14TH ST, SAN DIEGO, CA 92101-7586
(760) 845-8116
Mailing address
699 14TH ST, SAN DIEGO, CA 92101-7586
Taxonomy
Speciality
Code
Description
License number
State
1710I1002X
Independent Duty Corpsman
Primary
—
—
Other
Enumeration date
10/06/2013
Last updated
10/06/2013
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