| NPI | 1164532669 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: OR 2715T) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: WA OD00003478) |
| Enumeration Date | 2006-08-30 |
| Last Update Date | 2007-07-08 |