| NPI | 1295829752 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: MN 1908) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: WI 1876) |
| Enumeration Date | 2006-10-02 |
| Last Update Date | 2007-07-09 |