| NPI | 1205143252 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: MO 2010028684) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: TX 7597T) |
| Enumeration Date | 2010-09-10 |
| Last Update Date | 2012-02-14 |