| NPI | 1306288105 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: WA 60575301) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: ND 709) |
| Enumeration Date | 2013-07-22 |
| Last Update Date | 2018-12-07 |