| NPI | 1245386481 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: MS 482) |
| Additional Taxonomies | 332B00000X Durable Medical Equipment & Medical Supplies (Licence: MS 482) |
| 332H00000X Eyewear Supplier (Licence: MS 482) | |
| Enumeration Date | 2007-01-27 |
| Last Update Date | 2008-05-28 |