| NPI | 1306860077 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: IA 1923) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: MI 4911c03340) |
| Enumeration Date | 2006-07-27 |
| Last Update Date | 2007-07-08 |