| NPI | 1215308010 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: CA 34225) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: MI 4901004936) |
| Enumeration Date | 2015-10-19 |
| Last Update Date | 2023-07-27 |