| NPI | 1164457800 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: MO 2001018944) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: KS 1661) |
| Enumeration Date | 2006-07-11 |
| Last Update Date | 2007-07-08 |