| NPI | 1285972646 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: OH opt6718) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: MI 4901004747) |
| Enumeration Date | 2013-01-19 |
| Last Update Date | 2019-03-06 |