| NPI | 1235275983 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: NE 1272) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: WI 3053-035) |
| Enumeration Date | 2007-01-29 |
| Last Update Date | 2014-09-02 |