| NPI | 1053540724 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: MI 4901004555) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: VA 0618001848) |
| Enumeration Date | 2009-07-02 |
| Last Update Date | 2013-12-05 |