| NPI | 1265988810 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: ID ODP100398) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: OR ATI4295) |
| Enumeration Date | 2016-09-01 |
| Last Update Date | 2021-04-14 |