| NPI | 1164614996 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: GA OPT002445) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: AL S-B29-TA-734) |
| Enumeration Date | 2007-08-15 |
| Last Update Date | 2011-01-12 |