| NPI | 1255490942 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: GA OPT000690) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: MN 1511) |
| Enumeration Date | 2006-12-08 |
| Last Update Date | 2023-03-07 |