| NPI | 1164568556 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: TN 1018) |
| Additional Taxonomies | 332H00000X Eyewear Supplier (Licence: TN 0752740001) |
| Enumeration Date | 2007-01-30 |
| Last Update Date | 2008-04-22 |