| NPI | 1205297835 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: WA OD60632311) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: CA 33349) |
| Enumeration Date | 2016-03-09 |
| Last Update Date | 2016-10-04 |