| NPI | 1134216724 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: CO 1559) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: WA 4102) |
| 152W00000X Optometrist (Licence: PA 7351) | |
| Enumeration Date | 2006-10-06 |
| Last Update Date | 2007-07-08 |