| NPI | 1083195374 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: OH T6637) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: MI 4901005408) |
| Enumeration Date | 2018-08-24 |
| Last Update Date | 2023-01-05 |