| NPI | 1255802401 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: MI 4901005184) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: PR 741-0438) |
| 152W00000X Optometrist (Licence: WI 3541-35) | |
| Enumeration Date | 2018-12-16 |
| Last Update Date | 2020-10-01 |