Individual
FONTAINE WILLIS
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Contact information
Practice address
4420 N VARSITY AVE APT 1040, SAN BERNARDINO, CA 92407-4636
(213) 949-6845
Mailing address
4420 N VARSITY AVE APT 1040, SAN BERNARDINO, CA 92407-4636
(213) 949-6845
Taxonomy
Speciality
Code
Description
License number
State
172A00000X
Driver
Primary
Y7940726
CA
Other
Enumeration date
01/28/2021
Last updated
01/28/2021
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