| NPI | 1003906140 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: NC 1783) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: SC 1135) |
| Enumeration Date | 2006-10-12 |
| Last Update Date | 2021-03-25 |