| NPI | 1124284997 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: WY 327T) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: WA OD60035926) |
| Enumeration Date | 2008-07-31 |
| Last Update Date | 2013-09-27 |