| NPI | 1265927040 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: NC 2545) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: SC 2076) |
| Enumeration Date | 2018-06-25 |
| Last Update Date | 2023-01-18 |