| NPI | 1306493978 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: OR 4465) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: WA OD60966063) |
| Enumeration Date | 2019-08-19 |
| Last Update Date | 2019-08-19 |