| NPI | 1073561981 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: PA 0EG001179) |
| Additional Taxonomies | 332H00000X Eyewear Supplier (Equipment, not the service) (Licence: PA OEG00179) |
| Enumeration Date | 2006-05-04 |
| Last Update Date | 2012-03-30 |