| NPI | 1164863544 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: CA 15451TLG) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: PA OEG002825) |
| Enumeration Date | 2013-07-12 |
| Last Update Date | 2016-09-27 |