| NPI | 1114019056 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: CO 835) |
| Additional Taxonomies | 332B00000X Durable Medical Equipment & Medical Supplies |
| 332H00000X Eyewear Supplier (Equipment, not the service) | |
| Enumeration Date | 2006-09-29 |
| Last Update Date | 2008-05-08 |