| NPI | 1083104962 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: CT 3113) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: SC 2052) |
| Enumeration Date | 2018-05-16 |
| Last Update Date | 2020-12-01 |