Individual
MR. MATTHEW ALEXANDER BLAKE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
IDC
Contact information
Practice address
1336 BRUNNER ST APT H, SAN DIEGO, CA 92110-1690
(931) 865-6165
Mailing address
1336 BRUNNER ST APT H, SAN DIEGO, CA 92110-1690
(931) 865-6165
Taxonomy
Speciality
Code
Description
License number
State
1710I1002X
Independent Duty Corpsman
Primary
—
—
Other
Enumeration date
03/13/2018
Last updated
03/13/2018
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