| NPI | 1013218254 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: SC 1403) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: NC 1766) |
| Enumeration Date | 2010-11-04 |
| Last Update Date | 2019-04-23 |