| NPI | 1336130012 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: MI KM002606) |
| Additional Taxonomies | 152WS0006X Optometrist, Sports Vision (Licence: MI KM002606) |
| Enumeration Date | 2005-11-02 |
| Last Update Date | 2010-06-28 |