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Individual

MR. WYATT BLUE

Active
Sole proprietor
Yes

Provider details

NPI number
Gender
Man
Credential
MS, LAT, ATC, CSCS

Contact information

Practice address
1732 MACKINNON AVE, CARDIFF BY THE SEA, CA 92007-1605
(603) 812-6913
Mailing address
1732 MACKINNON AVE, CARDIFF BY THE SEA, CA 92007-1605
(603) 812-6913

Taxonomy

Speciality
Code
Description
License number
State
171W00000X
Contractor
Primary
0506246
NV

Other

Enumeration date
04/03/2013
Last updated
01/16/2014
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