| NPI | 1154432938 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: ID ODP-992) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: NV 1040) |
| 152W00000X Optometrist (Licence: UT 11319935-9934) | |
| Enumeration Date | 2006-08-31 |
| Last Update Date | 2019-09-27 |