| NPI | 1043361843 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: IA 02254) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: SD 618) |
| 152W00000X Optometrist (Licence: NE 1210) | |
| 152WV0400X Optometrist, Vision Therapy (Licence: NE 386) | |
| Enumeration Date | 2007-01-16 |
| Last Update Date | 2018-10-22 |