| NPI | 1295264547 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: MN 3609) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: NE 1473) |
| Enumeration Date | 2017-06-09 |
| Last Update Date | 2021-08-10 |