| NPI | 1073869293 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: MI 4901004702) |
| Additional Taxonomies | 332H00000X Eyewear Supplier (Equipment, not the service) (Licence: MI 4901004702) |
| Enumeration Date | 2012-07-25 |
| Last Update Date | 2022-07-29 |