| NPI | 1053611996 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: RI CODTG00551) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: MA 4822) |
| Enumeration Date | 2010-10-26 |
| Last Update Date | 2016-04-12 |