| NPI | 1104898014 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: WA OD00004177) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: FL OPC4062) |
| Enumeration Date | 2006-02-03 |
| Last Update Date | 2009-07-20 |