| NPI | 1174651749 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: AL S-A45-TA-615) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: LA 1273-432t) |
| Enumeration Date | 2007-03-02 |
| Last Update Date | 2019-11-08 |