| NPI | 1316508708 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: MI 4901005485) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: OH OPT.006797) |
| Enumeration Date | 2019-06-26 |
| Last Update Date | 2022-06-28 |