| NPI | 1104930619 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: CT 000910) |
| Additional Taxonomies | 335E00000X Prosthetic/Orthotic Supplier (Licence: CT 000910) |
| Enumeration Date | 2006-08-19 |
| Last Update Date | 2008-03-26 |