| NPI | 1316939051 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: MO 2008-026019) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: KS 12392) |
| 152W00000X Optometrist (Licence: MO 2008026019) | |
| Enumeration Date | 2005-08-18 |
| Last Update Date | 2011-05-24 |