| NPI | 1164570230 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: TN OD0001030) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: GA OPT001085) |
| Enumeration Date | 2007-01-08 |
| Last Update Date | 2012-02-27 |