| NPI | 1053604397 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: ND 693) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: MN 3250) |
| Enumeration Date | 2011-05-19 |
| Last Update Date | 2012-10-09 |