| NPI | 1306926753 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: CO 1911) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: MN 2999) |
| 152W00000X Optometrist (Licence: WI 3006) | |
| Enumeration Date | 2006-10-17 |
| Last Update Date | 2007-07-08 |