| NPI | 1174622245 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: ND 670) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: MN 3051) |
| Enumeration Date | 2006-09-22 |
| Last Update Date | 2011-02-27 |