| NPI | 1104898220 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: CO 1128) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: CO OPT.0001128) |
| Enumeration Date | 2006-02-02 |
| Last Update Date | 2016-03-10 |