| NPI | 1134359946 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: WA OD60101533) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: CA OPT13808PLG) |
| Enumeration Date | 2009-07-15 |
| Last Update Date | 2010-05-04 |