| NPI | 1215168141 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: KS 1901) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: TX 7447TG) |
| Enumeration Date | 2009-07-27 |
| Last Update Date | 2016-01-28 |