| NPI | 1003890609 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: TN 3158) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: MN 2763) |
| Enumeration Date | 2005-12-06 |
| Last Update Date | 2022-08-08 |