| NPI | 1114013166 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: AL S741TA186) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: FL OPC2793) |
| Enumeration Date | 2006-10-05 |
| Last Update Date | 2013-01-04 |