| NPI | 1316358245 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: SC 1383) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: LA 958-224T) |
| 152W00000X Optometrist (Licence: TX 3170T) | |
| Enumeration Date | 2014-05-13 |
| Last Update Date | 2016-11-29 |