| NPI | 1235364373 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: ND 678) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: MN 3184) |
| Enumeration Date | 2009-05-19 |
| Last Update Date | 2011-02-25 |