| NPI | 1265870133 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: LA 1855-789AT) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: TX 8282T) |
| Enumeration Date | 2013-06-12 |
| Last Update Date | 2020-09-01 |