| NPI | 1124123567 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: MN 1928) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: WI 1879) |
| 152W00000X Optometrist (Licence: OR 1599) | |
| Enumeration Date | 2006-09-13 |
| Last Update Date | 2007-07-08 |