| NPI | 1275503856 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: MI 4901004506) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: AZ 1176) |
| Enumeration Date | 2006-01-25 |
| Last Update Date | 2011-11-07 |