| NPI | 1285695916 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: GA OPT002219) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: AL R117-TA-093) |
| 152W00000X Optometrist (Licence: FL OPC0843) | |
| Enumeration Date | 2006-03-31 |
| Last Update Date | 2022-04-22 |