| NPI | 1104072107 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: KS 1820) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: MO 2008024282) |
| Enumeration Date | 2008-08-11 |
| Last Update Date | 2012-04-03 |