| NPI | 1104839661 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: MO 1999137663) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: NE 1235) |
| 152W00000X Optometrist (Licence: IA 02126) | |
| Enumeration Date | 2006-08-15 |
| Last Update Date | 2008-08-26 |