| NPI | 1316272495 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152WS0006X Optometrist, Sports Vision (Licence: MN 3304) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: MN 3304) |
| 152WV0400X Optometrist, Vision Therapy (Licence: MN 3304) | |
| Enumeration Date | 2009-10-07 |
| Last Update Date | 2012-08-20 |