| NPI | 1003818964 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: NC NC1779) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: GA OPT002735) |
| Enumeration Date | 2005-08-11 |
| Last Update Date | 2019-01-21 |