| NPI | 1306864426 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: WA 1466TX) |
| Additional Taxonomies | 332H00000X Eyewear Supplier (Equipment, not the service) (Licence: WA 1466TX) |
| Enumeration Date | 2006-07-17 |
| Last Update Date | 2021-04-13 |